Product Discontinuance Notice for QHP Issuers

Annual Eligibility Redetermination, Product Discontinuation and Renewal Notices (CMS-10527)

Documents and Forms

Document Name Document Type
Form CMS-10527 Product Discontinuance Notice for QHP Issuers Form and Instruction
CMS-10527 Discontinuation Notices CMS-10527 Attachment 4 - Discontinuation Notice with auto enrollment QHP.pdf Form and Instruction
CMS-10527 Discontinuation Notices CMS-10527 Attachment 4 - Discontinuation Notice with auto enrollment QHP 30-day rev.pdf Form and Instruction
CMS-10527 Discontinuation without auto enrollment (QHP) CMS-10527 Attachment 6 - Discontinuation Notice without auto enrollment QHP 30 - day clean.pdf Form and Instruction
CMS-10527 Discontinuation without auto enrollment (QHP) CMS-10527 Attachment 6 - Discontinuation Notice without auto enrollment QHP 30 - day clean.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Product Discontinuance Notice for QHP Issuers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 156.1255 45 CFR 147.106

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-10527	Discontinuation Notices	CMS-10527 Attachment 4 - Discontinuation Notice with auto enrollment QHP 30-day rev.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10527	Discontinuation without auto enrollment (QHP)	CMS-10527 Attachment 6 - Discontinuation Notice without auto enrollment QHP 30 - day clean.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 333	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	666	178	488
Annual IC Time Burden (Hours)	4,829	1,291	3,538
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.