CMS-10527 Renewal Notice

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

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 we’ll
automatically re-enroll you 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], we’ll automatically keep you in this plan for [8 Year].
[9 Plan name] isn’t an [10 Exchange] plan. You won’t get any financial help lowering your
monthly premium or out-of-pocket costs (like deductibles, copayments, and coinsurance) if
you stay in this plan].
• To find out if you qualify for these savings and to enroll in a plan through [11 Exchange],
visit [12 Exchange website] by [13 Date].
• If you don’t enroll in a plan through [14 Exchange] by [15 Date], you may not be able to
do so for [16 Year], even if your finances change.

What’s changing in [ 17 Year]
Your new premium
• Starting in [18 Month], your [19 estimated] monthly premium in [20 Plan name]
will be $[21 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 premium amount when you get your [22 Month]
bill.
•

Your [23 Current year] monthly premium is $[24 Dollar amount].
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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 at [28 SBC web page].

What you need to do
Decide if you want to enroll in [29 plan name] or choose another one.
 I want to enroll in this plan.
Pay the new monthly premium [30 by Date] and you’ll be automatically enrolled.
 I want to pick a different plan.
[31 You can choose a different plan between [32 Dates]. Enroll by [33 Date] for coverage
to start [34 Date].]
Here are some ways to find other plans and enroll:
•
•

Check with [35 Issuer] to see what other plans may be available. Remember, you
won’t get financial help unless you qualify and enroll through [36 Exchange].
Visit [37 Exchange website] to see [38 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.

We’re here to help
• Call [39 Issuer] at [40 Issuer phone number] or visit [41 Issuer website].
• Visit [42 Exchange website], or call [43 Exchange phone number] to learn more about
[44 Exchange] and to see if you qualify for lower costs.
• Find in-person help from an assister, agent, or broker in your community at [45
Website]
• [46 Contact an agent or broker you've worked with before [47 like Agent/broker name].
[48 Call Agent/broker phone number].]
• [49 Call [50 Issuer phone number] to get this information in an accessible format, like
large print, Braille, or audio, at no cost to you.]

[51 Getting help in other languages]
[52 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 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 Exchange and will be
renewed outside the Exchange. 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 plan selection must be made, 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 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 plan name.
Item 10. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Health
Insurance Marketplace®.”
Item 11. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 12. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 13. Enter the date by which a plan selection must be made, in format Month DD.
Item 14. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 15. Enter the date by which a plan selection must be made, in format Month DD.
Item 16. For calendar year plans enter the following year, in format YYYY. For non-calendar
year plans, enter the phrase “until Open Enrollment.”
Item 17. For calendar year plans enter the following year, in format YYYY. For non-calendar
year plans, enter the phrase “the next policy year.”
Item 18. Enter the beginning month of the following policy year.

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Item19. 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 20. Enter plan name
Item 21. Enter the monthly amount of premium for the enrollment group for which data are
available, for the following policy year.
Item 22. Enter the month in which the enrollee will receive a bill for the actual monthly
premium for the following policy year.
Item 23. If a calendar year plan, enter the current year, in format YYYY. If a non-calendar year
plan, enter the word “current.”
Item 24. Enter the most recent monthly amount of premium for the enrollment group for which
data are available, for the current 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 the SBC webpage for the applicable plan.
Item 29. Enter plan name.
Item 30. Enter "by" and due date for first premium for following policy year or omit and skip to
item 31.
Item 31. 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 item35. Under 45 CFR 147.104(b) and 155.420(d), consumers in a
non-calendar year plan qualify for a special enrollment period based on a policy year that ends
on a non-calendar year basis.
Item 32. Enter the beginning and end dates of the annual open enrollment period for the
applicable benefit year, in format Month DD, YYYY.
Items 33 and 34. 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 35. Enter the issuer name.
Item 36. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 37. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 38. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 39. Enter the issuer name.
Item 40. Enter issuer phone number.
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Item 41. Enter the issuer website.
Item 42. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 43. Enter the Exchange phone number. For a Federally-facilitated Exchange, enter “1-800318-2596 (TTY: 1-855-889-4325).”
Item 44. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 45. Enter LocalHelp.HealthCare.gov in a State with a Federally-facilitated Exchange. In
other States, enter the appropriate website.
Item 46. Include this phrase if the enrollee has previously used an agent or broker to enroll.
Otherwise, omit and skip to item 49.
Item 47. Insert “like” followed by the name of the agent or broker the enrollee previously used,
if known. Otherwise, omit and skip to item 49.
Item 48. Insert “Call” followed by the phone number of the agent or broker the enrollee
previously used, if known. Otherwise, omit and skip to item 49.
Item 49. 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 51.
Item 50. Enter issuer phone number and issuer TTY number.
Item 51. Insert “Getting Help in Other Languages” if adding a tagline pursuant to instruction 52.
Otherwise, leave blank.
Item 52. 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
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,
1

45 CFR 92.101.

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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.
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 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.

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