CMS-10527 Federal Standard Notices

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

Attachment 5: Discontinuation notice for the individual market outside the Exchange and
the issuer is not automatically enrolling the enrollee in a different plan
[1 Date]
[2 [First Name][Last Name]
[Address line 1]
[Address line 2]
[City][State][Zip]]

Important: Your health coverage is ending. Take action by [3 Date], or you won’t have health
coverage in [4 Year].

Thank you for choosing [5 Issuer] for your health care needs. [6 We’re here to help you prepare
for Open Enrollment.]

Why am I getting this letter?
Starting [7 Date], we won’t offer your current health coverage [8 in your area]. You must
enroll in a new plan to keep health coverage. The last day of your current coverage is [9 Date].
Read this letter carefully and review your options.
You can choose a different plan between [10 Dates]. Enroll in a different plan by [11 Date] to
avoid a gap in your coverage.

What you need to do
Review your coverage options and pick a different plan. If you don’t have health coverage,
you’ll have to pay for all of your health care.
Here are some ways to look at other plans and enroll:
• Check with [12 Issuer] to see what other plans may be available. You won’t get financial
help unless you qualify and enroll through [13 Exchange].
•

Visit [14 Exchange website] to see [15 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 [16 Issuer] at [17 Issuer phone number] or visit [18 Issuer website].

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•
•

Visit [19 Exchange website], or call [20 Exchange phone number] to learn more about
[21 Exchange] and to see if you qualify for lower costs.
Find in-person help from an assister, agent, or broker in your community at [22 Website].

•

[23 Contact an agent or broker you’ve worked with before [24 like Agent/broker name].
[25 Call Agent/broker phone number].]

•

[26 Call [27 Issuer phone number] to get this information in an accessible format, like
large print, Braille, or audio, at no cost to you].

[28 Getting help in other languages]
[29 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 5 – Discontinuation notice for the individual market outside
the Exchange and the issuer is not automatically enrolling
the enrollee in a different plan
General instructions:
This notice must be used when the issuer is non-renewing coverage purchased outside the
Exchange 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, and not automatically enrolling the
enrollee in a different plan. 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. 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) to avoid a gap in coverage, in format Month DD, YYYY.
Item 4. 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 5. Enter the issuer name.
Item 6. 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 7.
Item 7. 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 8. Enter the phrase “in your area” if non-renewing or terminating based on the fact that
there is no longer being any enrollee in the plan who live, resides, or works within the product’s
service area. Otherwise, omit and skip to item 9.
Item 9. Enter the last day on which the enrollee’s current coverage will remain in force, in
format Month DD, YYYY.
Item 10. 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 annual open enrollment period, enter
the end date of the open enrollment period, in format Month DD, YYYY.
Item 11. 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) to avoid a gap in coverage, in format Month DD, YYYY.
Item 12. Enter the issuer name.

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Item 13. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the Health
Insurance Marketplace®.”
Item 14. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 15. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 16. Enter the issuer name.
Item 17. Enter issuer phone number.
Item 18. Enter issuer website.
Item 19. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 20. Enter the Exchange phone number. For a Federally-facilitated Exchange, enter “1-800318-2596 (TTY: 1-855-889-4325).”
Item 21. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 22. Enter LocalHelp.HealthCare.gov in a State with a Federally-facilitated Exchange. In
other States, enter the appropriate website.
Item 23. Include this phrase if the enrollee has previously used an agent or broker to enroll.
Otherwise, omit and skip to item 26.
Item 24. Enter “like” followed by the name of the agent or broker the enrollee has previously
used, if known. Otherwise, omit and skip to item 26.
Item 25. Enter “Call” followed by the phone number of agent or broker the enrollee has
previously used, if known. Otherwise, omit skip to item 26.
Item 26. 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 28.
Item 27. Enter issuer phone number and issuer TTY number.
Item 28. Insert “Getting Help in Other Languages” if adding a tagline pursuant to instruction 29.
Otherwise, leave blank.
Item 29. 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.

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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
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 4.5 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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