CMS-10527 Discontinuation Notices

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

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 not be offered through the [3 Exchange] [4 in your area] next year.
Take action by [5 Date] or we’ll automatically enroll you in a different [6 Exchange] plan. This
may change some of your costs and coverage, so review your options carefully.
Thank you for choosing [7 Issuer] for your health care needs. [8 We’re here to help you prepare
for Open Enrollment].

Why am I getting this letter?
Starting [9 Date], we won’t offer [10 in your area] your current health coverage [11 in the
Exchange]. The last day of your current [12 Exchange] coverage is [13 Date]. Read this letter
carefully and review your options. Also make sure to update your information with [14
Exchange].

Your new plan for [15 Year]
We found another [16 Exchange] plan that may meet your needs. If you don’t pick another plan
by [17 Date], we’ll automatically enroll you in [18 Plan name]. Your coverage in [19 Plan name]
will start in [20 Month]. (Get details on picking another plan in “What you need to do” below.)
Your new premium
• Starting in [21 Month], your new monthly payment is estimated to be: $[22 Dollar
amount].
Here’s the math: Monthly premium of $[23 Dollar amount] minus [24 Phrase or dollar
amount] of possible cost help. Your actual monthly payment may be different because
your financial help may change [25 in Year]. You’ll find out your new monthly payment
when you receive your [26 Month] bill.
Important: This estimated monthly payment is based on current information we have for
[27 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 [28 Exchange] application. Get details in “What you need to do” below.
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•

Your [29 Current Year] monthly payment is $[30 Dollar amount].
Here’s the math: Monthly premium of $[31 Dollar amount] minus $[32 Dollar amount]
of financial help you get each month.

•

[33 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, [34 Exchange]
may enroll you in a Silver plan from [35 issuer] so you’ll get the most help to lower your
costs in [36 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.

•

[37 Exchange] may contact you about [38 this and] other reenrollment options if you
don’t choose a different plan on your own during open enrollment.

•

[39 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, [40 Exchange] is enrolling you in a
Silver plan from [41 issuer] so you’ll get the most help to lower your costs in [42 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
• [43 Briefly describe plan changes and/or refer to enclosed materials]
• You can review more details about this plan at [44 Issuer website] and in your [45 Year]
Summary of Benefits and Coverage at [46 SBC web page].
If you want to pick another plan, enroll by [47 Date] to make sure you have the coverage
you want. See below for more information.

What you need to do
1. Update your [48 Exchange] application by [49 Date].
Review and if necessary, update your [50 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 [51 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.
2. Decide if you want to enroll in this plan or choose another one.
 I want to enroll in this plan
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Select [52 Plan name and ID] to enroll.
[53 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 [54 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 [55 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 [56 Date].]
 I want to pick a different plan.
• You can choose a different plan between [57 Dates]. Enroll by [58 Date] for
coverage to start [59 Date]. [60 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 [61 Exchange website] to see other [62 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 [63 Issuer] to see what other plans may be available.
[64 Important: You may be able to keep your current coverage, but [65 in
Year] it won’t be offered [66 as a Silver plan] through [67 Exchange.]
Remember, you won’t get financial help [68 to lower your out-of-pocket
costs] unless you qualify and enroll [69 in a Silver plan] through [70
Exchange].]
Note: If you got financial help in [71 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 [72 Year] with the amount you
actually qualify for based on your final [73 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 [74 Exchange website], or call [75 Exchange phone number] to learn more about
[76 Exchange] and to see if you qualify for lower costs.
Call [77 Issuer] at [78 Issuer phone number] or visit [79 Issuer website].
Find in-person help from an assister, agent, or broker in your community at [80 Website].
[81 Contact an agent or broker you've worked with before [82 like Agent/broker name].
[83 Call Agent/broker phone number].]
Call [84 Exchange phone number] to get this information in an accessible format, like
large print, Braille, or audio, at no cost to you.
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[85 Getting help in other languages]
[86 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 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

General instructions:
This notice must be used when the QHP enrollee’s current product is not available for renewal
through the Exchange (even if it remains available outside the Exchange) 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 Exchange. 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 Exchange, and the enrollee will, consistent with State law and, if applicable, 45 CFR
155.335(j), be automatically re-enrolled in a silver level QHP under a different product offered
by the same QHP issuer through 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 Exchange name. For a Federally-facilitated Exchange, enter “the Health
Insurance Marketplace®.”
Item 4. 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 5.
Item 5. Enter the date by which a plan selection must be made to avoid automatic re-enrollment,
in format Month DD, YYYY.
Item 6. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 7. Enter the issuer name.
Item 8. 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 9.
Item 9. Enter the first day on which the current plan will no longer be available, in format Month
YYYY.
Item 10. 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 11. If issuer will not offer the enrollee’s current product through the Exchange for the
following benefit year, or will offer the current product through the Exchange 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 Exchange in accordance with 45 CFR 155.335(j), include
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the phrase “in [the Exchange]” and enter the Exchange name. For a Federally-facilitated
Exchange, enter “the Marketplace.” Otherwise omit and skip to item 13.
Item 12. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 13. Enter the last day on which the enrollee’s current coverage will remain in force through
the Exchange, in format Month DD, YYYY.
Item 14. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 15. 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 16. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 17. 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.
Items 18 and 19. Enter the plan name in which the enrollee will be automatically re-enrolled.
Item 20. 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 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. 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 23. Enter the actual or estimated total monthly premium for the following benefit year.
Item 24. 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 25. Enter the following year, in format YYYY.
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.
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Item 28. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 29. Enter current year, in format YYYY.
Item 30. 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 31. Enter the most recent amount of monthly premium for the enrollment group for which
data are available for the current benefit year.
Item 32. 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 33. 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 37. If the Exchange has
completed the annual eligibility redetermination by the time of providing the notice, omit and
skip to item 39.
Item 34. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 35. Enter Issuer name.
Item 36. Enter the following year, in format YYYY.
Item 37. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 38. Enter “this and” if the enrollee is currently enrolled in a bronze level QHP. Otherwise,
omit and skip to item 39.
Item 39. 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 43.
Item 40. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 41. Enter Issuer name.
Item 42. Enter the following year, in format YYYY.
Item 43. 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 44. Enter the issuer website.
Item 45. 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.”
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Item 46. Enter SBC web page for the applicable plan.
Item 47. 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 48. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 49. Enter the date by which a plan selection must be made to avoid automatic reenrollment, in format Month DD, YYYY.
Item 50. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 51. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter “in” and 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 52. Enter plan name and HIOS Plan ID of plan into which the enrollee will be enrolled.
Item 53. 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 53.
Item 54. Enter the applicable benefit year, in format YYYY.
Item 55. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 56. Enter last day of the current policy year, in format Month DD, YYYY.
Item 57. 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 58 and 59. 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 60. 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 61.
Item 61. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 62. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 63. Enter the issuer name.
Item 64. Include this sentence only if enrollee’s current product remains available for renewal
for the following benefit year, whether through or outside of the Exchange. Otherwise, omit and
skip to item 68.

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Item 65. 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 66. Include the words “as a Silver plan” if the enrollee’s current product will no longer
include a Silver plan offered through the Exchange in the applicable benefit year.
Item 67. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 68. Enter the phrase “to lower your out-of-pocket costs” if you entered “as a Silver plan” in
item 66. Otherwise, omit and skip to item 70.
Item 69. Enter the phrase “in a Silver plan” if you entered “as a Silver plan” in item 66.
Otherwise, skip to item 71.
Item 70. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 71. Enter the current benefit year, in format YYYY.
Item 72. Enter the current benefit year, in format YYYY.
Item 73. Enter the current calendar year, in format YYYY.
Item 74. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 75. Enter the Exchange phone number. For a Federally-facilitated Exchange, enter “1-800318-2596 (TTY: 1-855-889-4325).”
Item 76. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 77. Enter the issuer name.
Item 78. Enter the issuer phone number.
Item 79. Enter the issuer website.
Item 80. Enter LocalHelp.HealthCare.gov in a State with a Federally-facilitated Exchange. In
other States, enter the appropriate website.
Item 81. Include this phrase if the enrollee has previously used an agent or broker to enroll.
Otherwise, omit and skip to item 84.
Item 82. Enter “like” followed by the name of the agent or broker the enrollee has previously
used, if known. Otherwise, omit and skip to item 84.
Item 83. Enter “Call” followed by the phone number of agent or broker the enrollee has
previously used, if known. Otherwise, omit and skip to item 84.
Item 84. Enter the Exchange phone number and the Exchange TTY number. For a Federallyfacilitated Exchange, enter “1-800-318-2596 (TTY: 1-855-889-4325).”
Item 85. Insert “Getting Help in Other Languages” if adding a tagline pursuant to instruction 82.
Otherwise, leave blank.
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Item 86. 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 otherwise
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 non-English 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
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.
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 9 hours
per response, including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

1

45 CFR 92.101.

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