CMS-10527 Discontinuation without auto enrollment (QHP)

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

Attachment 6: Discontinuation notice for the individual market where coverage being
discontinued was in a QHP offered through 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 may not 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 [8 in your area] your current health coverage [9 in the
Exchange]. The last day of your current [10 Exchange] coverage is [11 Date]. Read this letter
carefully and review your options.
You can choose a different plan between [12 Dates]. Enroll in a different plan by [13 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.
1. Update your [14 Exchange] application by [15 Date].
Review and if necessary, update your [16 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 in [17 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. Choose a different plan.
Here are some ways to look at other plans and enroll:
• Visit [18 Exchange website] to find other [19 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.
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If you don’t enroll in a plan on your own, [20 Exchange] may automatically enroll
you in a plan it picks for you.
[21 For enrollees currently enrolled in a bronze level QHP, insert:] Also, if you
currently have a Bronze category plan and qualify for extra savings, [22
Exchange] may enroll you in a Silver plan so you’ll get the most help to lower
your costs in [23 Year].
•

Check with [24 Issuer] to see what other plans may be available, including
whether the plan you now have can be purchased directly through [25 Issuer].
[26 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.]
[27 Important: You may be able to keep your current coverage, but in [28 Year],
it won’t be offered [29 as a Silver plan] [30 through the Exchange]]. Remember,
you won’t get financial help [31 to lower your out-of-pockets costs] unless you
qualify and enroll [32 in a Silver plan] through [33Exchange].

Note: If you got financial help in [34 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 [35 Year] with the
amount you actually qualify for based on your final [36 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/affordable-care-act/individuals-and-families/the-premium-taxcredit-the-basics

We’re here to help
•

Visit [37 Exchange website], or call [38 Exchange phone number] to learn more about
[39 Exchange] and to see if you qualify for lower costs.

•

Call [40 Issuer] at [41 Issuer phone number] or visit [42 Issuer website].

•

Find in-person help from an assister, agent, or broker in your community at [43 Website].

•

[44 Contact an agent or broker you’ve worked with before [45 like Agent/broker name].
[46 Call [Agent/broker phone number].]

•

Call [47 Exchange phone number] for a reasonable accommodation to get this
information in an accessible format, like large print, Braille, or audio, at no cost to you.

[48 Getting help in other languages]
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[49 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 6 – Discontinuation notice for the individual market where
coverage being discontinued was in a QHP offered
through the Exchange and the issuer is not automatically
enrolling the enrollee in a different plan
General instructions:
This notice must be used when the QHP enrollee’s product is not available for renewal through
or outside the Exchange and the issuer is not automatically enrolling the enrollee in a different
plan through the Exchange. This includes non-renewals or terminations based on a product
discontinuation or there no longer being any enrollee in the plan who lives, resides or works
within the product’s service area. This notice must also be used when the QHP enrollee’s current
product is not available for renewal through the Exchange but remains available for renewal
outside the Exchange, and the issuer no longer has plans available for re-enrollment 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. 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), in order 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 any enrollee under the plan who lives, resides, or works in the product’s
service area. Otherwise, omit and skip to item 9.
Item 9. Include this phrase if issuer will not offer the enrollee’s current product through the
Exchange for the following benefit year (even if the product remains available for renewal
outside the Exchange). In such cases, for a Federally-facilitated Exchange, enter “the Health
Insurance Marketplace®.” Otherwise omit and skip to item 10.

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Item 10. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.” Note that if Item 9 isn’t included, enter “the Health Insurance Marketplace®. (The
first instance is the full name, and subsequent references is “Marketplace”.)
Item 11. Enter the last day on which the enrollee’s current coverage will remain in force through
the Exchange, in format Month DD, YYYY.
Item 12. 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 beginning and end date of the open enrollment period, in format Month DD, YYYY.
Item 13. 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 14. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 15. Enter the date by which a plan selection must be made to avoid automatic reenrollment, in format Month DD, YYYY.
Item 16. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 17. 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 18. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 19. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 20. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 21: Include this paragraph if the enrollee is currently enrolled in a bronze level QHP,
consistent with 45 CFR 155.335(j). Otherwise, omit and skip to item 24.
Item 22 Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 23. Enter the following year, in format YYYY.
Item 24 and Item 25. Enter the issuer name.
Item 26. 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 27.
Item 27. Include this sentence only if the enrollee’s current product remains available for
renewal for the following benefit year, whether through or outside the Exchange. Otherwise,
omit and skip to item 31.
Item 28. 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.
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Item 29. 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 30. Enter the word “through” followed by the Exchange name if either the words “as a
Silver” plan were entered in item 28 or the enrollee’s current product remains available outside
the Exchange, but no longer remains available for renewal through the Exchange. In this case,
enter the Exchange name. For a Federally-facilitated Exchange, enter “the Marketplace.”
Item 31. Enter the phrase “to lower your out-of-pocket costs” if the words “as a Silver plan”
were entered in item 29. Otherwise, omit and skip to item 32.
Item 32. Enter the phrase “in a Silver plan” if you entered “as a Silver plan” in item 29.
Otherwise, omit and skip to item 33.
Item 33. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 34. Enter the current benefit year, in format YYYY.
Item 35. Enter the current benefit year, in format YYYY.
Item 36. Enter the current calendar year, in format YYYY.
Item 37. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 38. Enter the Exchange phone number. For a Federally-facilitated Exchange, enter “1-800318-2596 (TTY: 1-855-889-4325).”
Item39. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 40. Enter issuer name.
Item 41. Enter issuer phone number.
Item 42. Enter issuer website.
Item 43. Enter LocalHelp.HealthCare.gov in a State with a Federally-facilitated Exchange. In
other States, enter the appropriate website.
Item 44. Include this phrase if the enrollee has previously used an agent or broker to enroll.
Otherwise, omit and skip to item 47.
Item 45. Enter “like” followed by the name of the agent or broker the enrollee has previously
used, if known. Otherwise, omit and skip to item 47.
Item 46. Enter “Call” followed by the phone number of agent or broker the enrollee has
previously used, if known. Otherwise, omit and skip to item 47.
Item 47. Enter the Exchange phone number and Exchange TTY number. For a Federallyfacilitated Exchange, enter “1-800-318-2596 (TTY: 1-855-889-4325).”
Item 48. Insert “Getting Help in Other Languages” if adding a tagline pursuant to instruction 49.
Otherwise, leave blank.
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Item 49. Insert a nondiscrimination notice and taglines consistent with any 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 5.5 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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