CMS-10527 Renewal and Discontinuance Notice

OMB Control No.: 0938-1254
Expiration Date: XX/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 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 we’ll
automatically re-enroll you in the same or similar coverage for [4 Year]. 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. 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. Also make
sure to update your information with [7 Exchange].

What’s changing in [8 Year]
Your new premium
• Starting in [9 Month], your new monthly payment is estimated to be $[10 Dollar
amount].
Here’s the math: Monthly premium of $[11 Dollar amount] minus [12 Phrase or dollar
amount] of possible help. Your actual monthly payment may be different because your
financial help may change in [13 Year]. You’ll find out your new monthly payment when
you get your [14 Month] bill.
Important: This estimated monthly payment is based on current information we have for
[15 Year]. It might not account for some or all changes that could impact your monthly
payment, like cost changes in your area for next year, or changes to your household
income or family size. To find out the actual amount of your monthly payment, update
your [16 Exchange] application. Get details in “What you need to do” below.
•

Your [17 Current year] monthly payment is $[18 Dollar amount].
Here’s the math: Monthly premium of $[19 Dollar amount] minus $[20 Dollar amount]
of financial help you get each month.
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•
•

[21 For enrollees currently enrolled in a bronze level QHP and the new plan to which the
premium information above applies, is a bronze level QHP, insert]: Important: If you
currently have a Bronze category plan and qualify for extra savings, [22 Exchange] may
enroll you in a Silver plan from [23 issuer] so you’ll get the most help to lower your costs
in [24 Year]. The Silver plan has the same network and an equal or lower monthly
payment as the new plan to which the premium information above applies, but covers
more of your out-of-pocket costs, like copayments, coinsurance and deductibles.
Enrolling in this (or another) Silver plan may save you thousands of dollars each year.
[25 Exchange] may contact you about [26 this and] other reenrollment options if you
don’t choose a different plan on your own during open enrollment.
[27 For enrollees currently enrolled in a bronze level QHP and who are being reenrolled in a silver level QHP by the Exchange per 45 CFR 155.335(j)(4), insert]:
Important: Since you qualify for extra savings, [28 Exchange] is enrolling you in a
Silver plan from [29 issuer] so you’ll get the most help to lower your costs in [30 Year].
The Silver plan will cover more of your out-of-pocket costs, like copayments,
coinsurance and deductibles. Enrolling in this (or another) Silver plan may save you
thousands of dollars each year.

Other changes
• [31 Briefly describe plan changes and/or refer to enclosed materials]
• You can review more details about your plan at [32 Issuer website] and in your [33
Year] Summary of Benefits and Coverage at [34 SBC web page].

What you need to do
1. Update your [35 Exchange] application by [36 Date].
Review and if necessary, update your [37 Exchange] 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 [38 Year]. This may result in a lower monthly payment or lower out-ofpocket 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.
Select [39 Plan name and ID] to enroll.
[40 For re-enrollment from a silver level QHP into a non-silver level QHP
(except for Indian enrollees), insert: Important: This isn’t a Silver plan in [41
Year]. You can’t get financial help to lower your out-of-pocket costs if you stay
in this plan. To get these savings if you qualify, you must go back to [42
Exchange] 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.
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You can choose a different plan between [43 Dates]. Enroll by [44 Date] for
coverage to start January 1. [45 Issuers on the Federally-facilitated Exchange or
on a State-based Exchange on the Federal platform, insert: If you choose a plan
between December 16 and January 15, the new plan will start February 1.]

Here are some ways to look at other plans and enroll:
•

Visit [46 Exchange website] to find other [47 Exchange] plans. Compare
plans to save money and find a plan that best meets your needs and budget.
Select the Plan name and ID of the plan you want to enroll in. Check with
[48 Issuer] to see what other plans may be available. Remember, you won’t
get financial help unless you qualify and enroll through [49 Exchange].

Note: If you got financial help in [50 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 got in advance during [51 Year] with the amount you
actually qualify for based on your final [52 Year] household income and eligibility information.
If the amounts are different, it may change the amount you owe or get back when you file your
taxes. For more information about the premium tax credit, visit: https://www.irs.gov/affordablecare-act/individuals-and-families/the-premium-tax-credit-the-basics.

We’re here to help
•
•
•
•
•

Visit [53 Exchange website], or call [54 Exchange phone number] to learn more about
[55 Exchange] and to see if you qualify for lower costs.
Call [56 Issuer] at [57 Issuer phone number] or visit [58 Issuer website].
Find in-person help from an assister, agent, or broker in your community at [59 Website].
[60 Contact an agent or broker you've worked with before [61 like Agent/broker name].
[62 Call Agent/broker phone number.]]
Call [63 Exchange phone number] to get this information in an accessible format, like
large print, Braille, or audio, at no cost to you.

[64 Getting help in other languages]
[65 insert non-discrimination notice and taglines consistent with any applicable state or federal
requirements. If there are no such requirements, see required non-discrimination notice and
optional taglines]

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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 Exchange and will be
renewed under the same product through the Exchange, in accordance with 45 CFR 155.335(j).
It doesn’t need to display the OMB control number.
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 following year, in format YYYY.
Item 5. Enter the issuer name.
Item 6. Enter the following year, in format YYYY.
Item 7. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the Health
Insurance Marketplace®.”
Item 8. Enter the following year, in format YYYY.
Item 9. Enter the beginning month of the following benefit year.
Item 10. 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 11. Enter the actual or estimated amount of monthly premium for the enrollment group for
which data are available for the following benefit year.
Item 12. Enter the phrase “the same amount of financial help you’re getting now” if the
Exchange has not completed the annual eligibility redetermination by the time of providing the
notice. If the Exchange has completed this redetermination by the time of providing the notice,
enter the amount of advanced payments of the premium tax credit calculated from that
redetermination.
Item 13. Enter the following year, in format YYYY.
Item 14. Enter the month in which the enrollee will receive a bill for the actual monthly payment
for the following benefit year.
Item 15. Enter the current year, in format YYYY.
Item 16. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 17. Enter the current year, in format YYYY.
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Item 18. 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. 19. Enter the most recent monthly amount of premium for the enrollment group for which
data are available for the current benefit year.
Item 20. 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 21. Include this paragraph if the enrollee is currently enrolled in a bronze level QHP, and
the new plan to which the premium information on this Notice applies, is a bronze level QHP,
consistent with 45 CFR 155.335(j). Otherwise, omit and skip to item 25. If the Exchange has
completed the annual eligibility redetermination by the time of providing the notice, omit and
skip to item 27.
Item 22. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 23. Enter Issuer name.
Item 24. Enter the following year, in format YYYY
Item 25. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 26. Enter “this and” if the enrollee is currently enrolled in a bronze level QHP. Otherwise,
omit and skip to item 31.
Item 27. Include this paragraph if the enrollee was previously enrolled in a bronze level QHP,
but was re-enrolled in a silver level QHP by the Exchange consistent with 45 CFR 155.335(j)(4).
If the Exchange has not completed the annual eligibility redetermination by the time of providing
the notice, omit and skip to item 31.
Item 28. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 29. Enter Issuer name.
Item 30. Enter the following year, in format YYYY.
Item 31. 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 cost-sharing reductions (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 32. Enter the issuer website.
Item 33. Enter the following year, in format YYYY.
Item 34. Enter SBC web page for the applicable plan.
Item 35. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 36. Enter the date by which a plan selection must be made to avoid automatic reenrollment, in format Month DD.
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Item 37. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 38. Enter the current benefit year, in format YYYY.
Item 39. Enter plan name and HIOS Plan ID of plan into which the enrollee’s coverage will be
renewed.
Item 40. 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 43.
Item 41. Enter the following benefit year, in format YYYY.
Item 42. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 43. Enter the beginning and end dates of the annual open enrollment period for the
applicable benefit year, in format Month DD, YYYY.
Item 44. Enter the date by which a plan selection must be made for coverage effective January 1,
in format Month DD, YYYY.
Item 45. Issuers on the Federally-facilitated Exchange, or on a State-based Exchange on the
Federal platform, enter the following phrase: “If you choose a plan between December 16 and
January 15, the new plan will start February 1.” Other issuers should omit, and skip to Item 46.
Item 46. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 47. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 48. Enter the issuer name.
Item 49. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Items 50-52. Enter the current benefit year, in format YYYY.
Item 53. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 54. Enter the Exchange phone number. For a Federally-facilitated Exchange, enter “1-800318-2596 (TTY: 1-855-889-4325).”
Item 55. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 56. Enter the issuer name.
Item 57. Enter the issuer phone number.
Item 58. Enter the issuer website.
Item 59. Enter LocalHelp.HealthCare.gov in a State with a Federally-facilitated Exchange. In
other States, enter the appropriate website.
Item 60. Include this phrase if the enrollee has previously used an agent or broker to enroll.
Otherwise, omit and skip to item 63.
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Item 61. Enter “like” followed by the name of the agent or broker the enrollee has previously
used, if known. Otherwise, omit and skip to item 63.
Item 62. Enter “Call” followed by the phone number of agent or broker the enrollee has
previously used, if known. Otherwise, omit and skip to item 63.
Item 63. Enter the Exchange phone number and Exchange TTY number. For a Federallyfacilitated Exchange, enter “1-800-318-2596 (TTY: 1-855-889-4325).”
Item 64. Insert “Getting Help in Other Languages” if adding a tagline pursuant to instruction
item 65. Otherwise, leave blank.
Item 65. Insert a nondiscrimination notice and taglines consistent with any applicable state or
federal requirements. If there are no such applicable non-discrimination requirements, insert the
following:
Health insurance issuers are prohibited from employing marketing practices or benefit designs
that will have the effect of discouraging the enrollment of individuals with significant health
needs in health insurance coverage or discriminate based on an individual's race, color, national
origin, present or predicted disability, age, sex (including sexual orientation and sexual identity),
expected length of life, degree of medical dependency, quality of life, or other health conditions.
Taglines are optional but encouraged for issuers outside the Exchange if they are not subject to
language access standards under applicable Federal or State law. As a reminder, issuers covered
by Section 1557 are responsible for providing timely and accurate language assistance in nonEnglish languages, regardless of whether 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. 1
If there are no such applicable tagline requirements, the following optional tagline may be
inserted:
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].

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 24 hours
per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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45 CFR 92.101.

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