Form CMS-10527 Discontinuation Notices

OMB Control No.: 0938-1254
Expiration Date: XX/XX/XXXX

Attachment: Renewal notice to employers for the small group market

Issuers in the small group market may use the draft Federal standard small group notices released
in the June 26, 2014 bulletin and provided below, or any forms of the notice otherwise permitted
by applicable laws and regulations. We expect issuers not using the form and manner of the draft
Federal standard notices released in the June 26, 2014 bulletin to include the content describe
d in the bulletin “Form and Manner of Notices When Discontinuing or Renewing a
p roduct in the Group or Individual Market”. The following is considered to be the
essential content contained in the form of the Federal standard renewal notices:
• Information about premiums and any advance payments of the premium tax credit
(APTC) for the plan in which the enrollee will be renewed in the next plan or policy year;
• Information about significant changes to the enrollee’s coverage;
• Information about other health coverage options; and
• Contact information for the consumer to call with questions.
The following draft standard notice from the June 26, 2014 bulletin may be used:
Important: We’re Continuing to Offer Your Group Health Coverage.

Dear [Plan Sponsor or Name1],
Your group health insurance coverage is coming up for renewal. On [Date 2], your group
members will be automatically re-enrolled and can keep your group’s current coverage.
Below are changes we’ll be making to the plan and options to consider to possibly lower your
costs or choose a new plan.
Changes we’re making to your group’s current coverage
• Premium – Your new premium starts in [Month3]. Your monthly premium will be $[Dollar
amount4]. This is an estimate based on current enrollment. This amount may change
depending on the individuals who actually enroll in the plan. Check to see if you have
other options at: [State Marketplace website/HealthCare.gov5]
• [List changes to renewed plan, including:
• Name of new plan and Plan ID
• Benefit changes
• Cost-sharing changes, including whether the plan is a different metal level from the
previous plan6].
[This plan isn’t being offered through [State SHOP Marketplace Name/the Small Business
Health Options (SHOP) Marketplace8]. If you’re eligible for a small business health care tax
credit, you usually can get that credit only if you buy insurance through [State SHOP
Marketplace Name/ the SHOP Marketplace9]7].
1

OMB Control No.: 0938-1254
Expiration Date: XX/XX/XXXX

Attachment: Renewal notice to employers for the small group market
What if I want to change plans?
•

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

•

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

•

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

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

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

Getting Help in Other Languages
[Include the tagline below for the top languages spoken by 10% or more of the population in the
state.
Spanish (Español): Para obtener asistencia en Español, llame al [Issuer contact information].18]
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1254. The time required to complete this information collection is estimated
to average 20 hours per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have
comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

2

OMB Control No.: 0938-1254
Expiration Date: XX/XX/XXXX

Attachment: Discontinuation notice to employers for the small group market

Issuers in the small group market may use the draft Federal standard small group notices released
in the June 26, 2014 bulletin and provided below, or any forms of the notice otherwise permitted
by applicable laws and regulations. We expect issuers not using the form and manner of the draft
Federal standard notices released in the June 26, 2014 bulletin to include the content
described in the bulletin “Form and Manner of Notices When Discontinuing or Renewing a
Product in the Group or Individual Market”. The following is considered to be the essential
content contained in the form of the Federal standard discontinuation notices:
• A statement that the coverage is being discontinued;
• If the individual is being auto-enrolled into another product, information about changes
in the individual’s benefits arising out of the change from the old product to the new
product;
• Information about other health coverage options; and
• Contact information for the consumer to call with questions.
The following draft standard notice from the June 26, 2014 bulletin may be used:

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

Dear [Plan Sponsor or Name1],
We have decided not to offer your group’s current health coverage again next year. The current
coverage will end on [Date2]. This means you may need to choose a new plan for your
group members to have health insurance coverage. This letter explains the options available
to you.
Options from [Issuer Name 3]
[We have selected a new [Issuer Name5] plan for your group members that’s similar to their
current plan. We’ll automatically enroll your group members in [Plan Name and Plan ID6]
unless you choose another option. Below are key differences between the new coverage
and the current coverage. You can review all the benefits and coverage for this plan at [Issuer
website7]].
•

•
•
•

Premium – Your new premium starts in [Month8]. Your monthly premium will be $[Dollar
amount9]. This is an estimate based on current enrollment. This amount may change
depending on the individuals who actually enroll in the plan. Check to see if you have
other options at: [State SHOP Marketplace website/HealthCare.gov10]
[List changes to new plan, including:
Benefit changes
Cost-sharing changes, including whether the plan is a different metal level from the
3

OMB Control No.: 0938-1254
Expiration Date: XX/XX/XXXX

Attachment: Discontinuation notice to employers for the small group market
previous plan11].
You can also choose any of our other small group plans available to you.4]
[You can choose any other small group coverage offered by [Issuer name 13]. Call [Issuer phone
number14] or visit [Issuer website15] to learn about plans available to you.12]
What other options do I have?
• You may be able to choose a new health plan, or offer your employees a choice of
plans, through different insurance companies, through [State SHOP Marketplace
Name/the SHOP Marketplace16]. If you have fewer than 25 full-time-equivalent
employees, you might qualify for a small business health care tax credit if you buy
insurance through [State SHOP Marketplace Name/the SHOP Marketplace17].
•

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

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

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

Getting Help in Other Languages
[Include the tagline below for the top languages spoken by 10% or more of the population in the
4

OMB Control No.: 0938-1254
Expiration Date: XX/XX/XXXX

Attachment: Discontinuation notice to employers for the small group market
state.
Spanish (Español): Para obtener asistencia en Español, llame al [Issuer contact information].24]

PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-1254. The time required to complete this information collection is estimated to average 12
hours per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy
of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

5

Attachment: Instructions for completing Federal standard notices

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

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

7

Attachment: Instructions for completing Federal standard notices

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

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

9