CMS-10527 Discontinuation Notices

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

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
[1 Date]
[2 [First Name][Last Name]
[Address line 1]
[Address line 2]
[City][State][Zip]]

Important: Your plan will no longer be offered next year. Take action by [3 Date], or we’ll
automatically enroll you 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?
Starting [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. If you don’t pick another plan by [10 Date],
we’ll automatically enroll you in [11 Plan name]. Your coverage in [12 Plan name] will start in
[13 Month]. (Get details on picking another plan in “What you need to do” below.)
[14 Plan name] isn’t an [15 Exchange] plan. You won’t get any financial help lowering your
monthly premium or out-of-pocket costs (like deductibles, copayments, and coinsurance) if
we automatically enroll you in this plan.
•

To see if you qualify for these savings and to enroll in a plan through [16 Exchange], visit
[17 Exchange website] by [18 Date].

•

If you don’t enroll in a plan through [19 Exchange] by [20 Date], you may not be able to
do so for [21 Year], even if your finances change.

Your new premium
• Starting in [22 Month], your [23 estimated] monthly premium in [24 Plan name] will
be $[25 Dollar amount].

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•

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 [26 Month]
bill.
Your current monthly premium is $[27 Dollar amount].

Other changes
• [28 Briefly describe plan changes and/or refer to enclosed materials]
•

You can review more details about this plan at [29 Issuer website] and in your [30 Year]
Summary of Benefits and Coverage at [31 SBC web page].

If you want to pick another plan, enroll by [32 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 [33 Plan name] or choose another one.
 I want to enroll in this plan.
Pay the monthly premium by [34 Date] and you’ll be automatically enrolled.
 I want to pick a different plan
• You can choose a different plan between [35 Dates]. Enroll by [36 Date] for
coverage to start [37 Date].

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

•

Check with [38 Issuer] to see what other plans may be available.
Visit [39 Exchange website] to see [40 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.
Remember, you won’t get financial help unless you qualify and enroll through
[41 Exchange].

We’re here to help
•
•
•
•
•

Call [42 Issuer] at [43 Issuer phone number] or visit [44 Issuer website].
Visit [45 Exchange website], or call [46 Exchange phone number] to learn more about
[47 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 [48 Website].
[49 Contact an agent or broker you've worked with before [50 like Agent/broker name].
[51 Call Agent/broker phone number].]
[52 Call [53 Issuer 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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[54 Getting help in other languages]
[55 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 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
Exchange as the result of a product discontinuance, and consistent with applicable State law,
automatically enrolling the enrollee in different coverage outside the 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. 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 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. 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
CCFR 147.104(b(4)(ii) 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 11 and 12. Enter the plan name for the plan in which the enrollee will be automatically
enrolled.
Item 13. Enter the first coverage month under the different plan, in format Month.
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Item 14. Enter the plan name for the plan in which the enrollee will be automatically enrolled.
Item 15. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Health
Insurance Marketplace®.”
Item 16. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 17. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 18. Enter the date by which a plan selection must be made, in format Month DD, YYYY.
Item 19. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 20. Enter the date by which a plan selection must be made, in format Month DD, YYYY.
Item 21. For calendar year plans enter the following year, in format YYYY. For non-calendar
year plans, enter the phrase “until Open Enrollment.”
Item 22. Enter the first month for the following policy year.
Item 23. 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 24. Enter the plan name for the plan in which the enrollee will be automatically enrolled.
Item 25. Enter the amount of monthly premium for the enrollment group for which data are
available for the following policy year.
Item 26. Enter the month in which the enrollee will receive their bill with the actual monthly
premium for the following policy year.
Item 27. Enter the most recent amount of monthly premium for the enrollment group for which
data are available for the current policy year.
Item 28. 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 29. Enter the issuer website.
Item 30. 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 31. Insert SBC web page for the applicable plan.
Item 32. Enter the date by which a plan selection must be made, in format Month DD, YYYY.
Item 33. Enter the plan name for the plan in which the enrollee will be automatically enrolled.
Item 34. Enter due date for first premium for following policy year or omit and skip to item 35.
Item 35. 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.
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Items 36 and 37. 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 38. Enter the issuer name.
Item 39. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 40. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 41. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 42. Enter the issuer name.
Item 43. Enter issuer phone number.
Item 44. Enter the issuer website.
Item 45. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 46. Enter the Exchange phone number. For a Federally-facilitated Exchange, enter “1-800318-2596 (TTY: 1-855-889-4325).”
Item 47. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 48. Enter LocalHelp.HealthCare.gov in a State with a Federally-facilitated Exchange. In
other States, enter the appropriate website.
Item 49. Include this phrase if the enrollee has previously used an agent or broker to enroll.
Otherwise, omit and skip to item 52.
Item 50. Enter “like” followed by the name of the agent or broker the enrollee has previously
used, if known. Otherwise, omit and skip to item 52.
Item 51. Enter “call” followed by the phone number of agent or broker the enrollee has
previously used, if known. Otherwise, omit and skip to item 52.
Item 52. 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 54.
Item 53. Enter issuer phone number and issuer TTY number.
Item 54. Insert “Getting Help in Other Languages” if adding a tagline pursuant to instruction 55.
Otherwise, leave blank.
Item 55. 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

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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 8 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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