Requests for Mailed Disclosures

OMB Control No. 0938-1372
Expiration Date: XX/XX/XXXX

APPENDIX 1:
Transparency in Coverage Model Notice
Instructions for the Transparency in Coverage Model Notice
The Departments of the Treasury, Labor, and Health and Human Services (the Departments) have issued
the Transparency in Coverage final rules (85 FR 72158) that require non-grandfathered group health
plans and health insurance issuers in the individual and group markets to disclose certain cost-sharing
information to a participant, beneficiary, or enrollee (or his or her authorized representative), upon
request. Under the final rules at 26 CFR 54.9815-2715A2, 29 CFR 2590.715-2715A2, and 45 CFR
147.211, a plan or issuer must provide an estimate of an individual’s cost-sharing liability for a covered
item or service, including the underlying information necessary to calculate the estimate. The plan or
issuer also must provide a notice of required prerequisites for the item or service, and a notice
explaining certain limitations that are applicable to the individual’s cost-sharing liability estimate.
This model notice satisfies the notice requirements under the final rules with respect to prerequisites
and the limitations of the cost-sharing information. 1 A plan or issuer may use this model notice when a
participant, beneficiary, or enrollee (or his or her authorized representative) requests cost-sharing
information in paper form or may incorporate the language contained in the model notice into the
internet-based self-service tool. A plan or issuer may modify or add information to the model notice,
provided the modification or additional information does not conflict with the information required to
be provided under the final rules. While this model notice sets out one method for providing the
required disclosures in plain language as required under the final rules, plans and issuers should
consider what terminology is best used in the disclosures to promote consistency across the range of
required disclosures and cost-sharing information.
Paperwork Reduction Act 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 Office of Management and Budget (OMB) control number. The
Departments are seeking OMB approval for the model notice as part of the approval for a new OMB
control number 0938-1372. The time required to complete this information collection is estimated to
average 23,313 hours per respondent to provide notice of any required prerequisites and the limitations
of the cost-sharing information made available through a self-service tool and 11 hours per respondent
in order to make the notice available in paper form, 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 C426-05, Baltimore, Maryland 21244-1850.

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85 FR 72158, 72307 (Nov. 12, 2020).

Transparency in Coverage Model Notice
[Name of Plan]
[Enter date of notice]
You are receiving this notice because you requested a cost estimate for an item or service. This
notice contains important information about the cost estimate and information on the amount
you may be required to pay for this item or service.
I.

The Basics

What should I do with this notice?
Read this notice carefully along with the cost estimate. You may need to request a new cost
estimate as you obtain new information, such as information on additional items or services
you will receive as part of your diagnosis, treatment, or procedure.
What are the key terms?
1. An Allowed Amount is the maximum amount your health plan will pay for a covered
item or service furnished by an out-of-network provider.
2. Cost Sharing is your share of costs for a covered item or service that you must pay
(sometimes called “out-of-pocket costs”). Some examples of cost sharing are
deductibles, coinsurance, and copayments. [include this if balance billing is
permitted under state law] This term does not include other costs you may be
responsible for, such as premiums, balance-billed amounts for out-of-network
providers, or the cost of items or services not covered by your health plan.
3. An Accumulated Amount is the amount of financial responsibility you have incurred
at the time a request for cost-sharing information is made, with respect to a
deductible or out-of-pocket limit.
4. A Covered Item or Service is an item or service that your health plan will pay for,
either in whole or in part, under the terms of your health plan.
5. An Out-of-Network Provider is a provider that does not have a contract with your
plan to provide the requested items or services at pre-negotiated rates.
6. Prerequisites are certain requirements your health plan may impose on you or your
provider so that your plan can determine whether a health care item or service,
including treatment plans, prescription drugs, or durable medical equipment, is
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medically necessary before your plan will provide benefits for these items and
services. For purposes of this estimate, prerequisites include prior authorization,
concurrent review, and step-therapy or fail-first requirements.
Other common medical and insurance terms, including definitions of deductibles, coinsurance,
and copayments, can be found in the Uniform Glossary of Coverage and Medical Terms
(https://www.dol.gov/sites/dolgov/files/EBSA/laws-and-regulations/laws/affordable-careact/for-employers-and-advisers/sbc-uniform-glossary-of-coverage-and-medical-termsfinal.pdf).
II.

Important information about your cost estimate

This estimate is designed to provide you with information about the cost of an item or service
before you receive care. However, this estimate has certain limitations that you should consider
before making any decision to receive the item or service.
1. [Include this if balance billing is permitted under state law] If you are treated by an outof-network provider, after paying the cost-sharing amount determined by your health
plan, you may still receive a bill for the difference between the amount the out-ofnetwork provider charges for the item or service and the amount paid by your health plan
for that same item or service. This is called balance billing, and this amount is not included
in your cost estimate.
2. The actual charge for the item or service may be different than the cost estimate,
depending on the actual care you receive. For example, if your physician provides
additional services during your visit, your charges could be more than the cost estimate.
This is one reason why it is important to discuss with your provider both before and during
your visit which items and services you will receive and to request a new cost estimate if
new information becomes available.
3. This cost estimate is not a benefit determination or guarantee of coverage for the item or
service for which you requested information. For example, your plan may need to
determine whether the item or service is medically necessary in your case before making
a payment. You should follow your health plan’s process for filing a claim for benefits and
contact your health plan to help determine if there are any additional requirements that
apply to you as part of that process.
4. [Include the applicable statement below]:
Your health plan counts copayment assistance and other third-party payments in the
calculation of your accumulated amounts (such as deductible and out-of-pocket
maximum amounts).

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Your health plan does not count copayment assistance and other third-party payments
in the calculation of your accumulated amounts (such as deductible and out-of-pocket
maximum amounts).
5. [Include if the item or service being considered may be a preventive item or service] An
in-network item or service may not be subject to cost sharing if it is billed as a
preventive service.
III.

Prerequisites (include the applicable portions of this section only if the item or service is
subject to the prerequisite in question)
a. [SELECT PLAN TERM: Prior Authorization, Preauthorization, Prior Approval or
Precertification]

Your health plan must decide whether this item or service is medically necessary before it will
cover this item or service. This is called [SELECT PLAN TERM: prior authorization,
preauthorization, prior approval or precertification]. Your health plan may impose additional
costs if you or your provider do not submit this item or service for [SELECT PLAN TERM: prior
authorization, preauthorization, prior approval or precertification] before the item or service is
provided.
b. Concurrent Review
Your health plan may require a review during an ongoing course of treatment to determine
whether the plan will continue to cover the item or service. This is called concurrent review.
Your health plan may cease covering treatment if you or your provider do not submit this item
or service for concurrent review within a specified time period after beginning your treatment
or procedure.
c. [SELECT PLAN TERM: Step-therapy or Fail-first requirement]
Your health plan will not pay for higher-cost therapies without evidence that certain lower-cost
therapies have not been effective for you (these are known as fail-first policies or step-therapy
requirements). You may be required to try a lower-cost alternative before your plan will cover
this particular item or service.
IV.

What if I need more information?

Contact: [Add contact information (including a phone number) for an individual or group of
individuals, such as a department or office, the person can call regarding their cost-sharing
liability estimate and questions.]

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