Product Discontinuance Notice for Issuers Outside the Marketplace (Non-QHP)

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

Documents and Forms

Document Name Document Type
Form CMS-10527 Product Discontinuance Notice for Issuers Outside the Marketplace (Non-QHP) Form and Instruction
CMS-10527 Discontinuation Notices CMS-10527 Attachment 3 - Discontinuation Notice with auto enrollment Off Exchange 30 -day.pdf Form and Instruction
CMS-10527 Discontinuation Notices CMS-10527 Attachment 3 - Discontinuation Notice with auto enrollment Off Exchange 30 -day.pdf Form and Instruction
CMS-10527 Federal Standard Notices CMS-10527 Attachment 5 - Discontinuation Notice without auto enrollment Off Exchange 30 - day.pdf Form and Instruction
CMS-10527 Federal Standard Notices CMS-10527 Attachment 5 - Discontinuation Notice without auto enrollment Off Exchange 30 - day.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Product Discontinuance Notice for Issuers Outside the Marketplace (Non-QHP)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 146.152 45 CFR 148.122 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 3 - Discontinuation Notice with auto enrollment Off Exchange 30 -day.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10527	Federal Standard Notices	CMS-10527 Attachment 5 - Discontinuation Notice without auto enrollment Off Exchange 30 - day.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,340	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	3,047	-1,138	4,185
Annual IC Time Burden (Hours)	22,481	-8,396	30,877
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.