Form CMS-10527 Discontinuation Notices

OMB Control No.: 0938-1254
Expiration Date: XX/XX/XXXX
Attachment 4: Notice for the individual market where coverage was in a QHP offered
through the Exchange and the issuer is automatically enrolling the enrollee in a plan under
a different product offered through the Exchange
[1 Date]
[2 [First Name][Last Name]
[Address line 1]
[Address line 2]
[City][State][Zip]]

Important: Your plan will not be offered through the [3 Exchange] [4 in your area] next year.
Update your [5 Exchange] application and pick a plan by [6 Date] or we’ll automatically
enroll you in a different [7 Exchange] plan. If you don’t update your application, some of your
costs and coverage may change, review your options carefully.
Thank you for choosing [8 Issuer] for your health care needs. [9 We’re here to help you prepare
for Open Enrollment].

Why am I getting this letter?
Starting [10 Date], we won’t offer your current health coverage [11 in your area] [12
through the Exchange]. The last day of your current [13 Exchange] coverage is [14 Date]. Read
this letter carefully and review your options, then update your application with [15 Exchange].

What’s changing in [16 Year]?
Your new plan
We found another [17 Exchange] plan that may meet your needs. If you don’t pick another plan
by [18 Date], we’ll automatically enroll you in [19 Plan name]. Your coverage in [20 Plan name]
will start in [21 Month]. For more information about picking a new plan,go to “What should I do
next?” below.
Your new premium
• Starting in [22 Month], your new monthly premium amount is estimated to be: $[23
Dollar amount].
Here’s the math: Monthly premium of $[24 Dollar amount] minus [25 Phrase or dollar
amount] of possible financial help. Your actual monthly premium amount may be
different because your financial help may change [26 in Year]. You’ll find out your new
monthly premium when you get your [27 Month] bill.
Important: This estimated monthly premium is based on current information we have
for [28 Year]. It might not account for some or all changes that could impact your

monthly premium, like cost changes in your area for next year, or changes to your
household income or family size. To find out the actual amount of your monthly
premium, update your [29 Exchange] application. For more information about updating
your application, go to “What should I do next?” below.
•

Your [30 Current Year] monthly premium amount is $[31 Dollar amount].
Here’s the math: Monthly premium of $[32 Dollar amount] minus $[33 Dollar amount]
of financial help you get each month.

Other changes
• [34 Briefly describe plan changes and/or refer to enclosed materials]
• You can review more details about this plan at [35 Issuer website] and in your [36 Year]
Summary of Benefits and Coverage at [37 SBC web page].
If you want to pick another plan, enroll by [38 Date] to make sure you have the coverage
you want.

What should I do next?
1. Update your [39 Exchange] application by [40 Date].
Review your [41 Exchange] application to make sure the information is still current and
correct and make any necessary updates. After you submit your updated application,
you’ll find out if you qualify for more or less financial help [42 in Year] than you’re
getting now. This could mean you’ll pay a lower monthly premium amount or lower outof-pocket costs (like deductibles, copayments, and coinsurance). Plus, you might not owe
money when you file your taxes.
[43 For automatic re-enrollment of consumers whose premium tax credit amount resulted
in a $0 premium in the current benefit year] Important: Our records show you had a $0
monthly premium amount in [44 Year]. You must update your application to qualify for a
$0 monthly premium amount in [45 Next Year]. Depending on your updated information,
your [45 Next Year] monthly premium amount could still be higher than it was in [46
Current Year].
2. Decide if you want to enroll in this plan or choose another one.
 I want to enroll in this plan
Select [47 Plan name and ID] to enroll.
[48 For re-enrollment from a silver level QHP into a non-silver level QHP (except for
Indian enrollees), insert: Important: This isn’t a Silver plan in [49 Year]. This
means you can’t get financial help to lower your out-of-pocket costs if you enroll in

this plan. You must go back to [50 Exchange] and enroll in a Silver plan to find out if
you qualify for financial help. If you don’t enroll in a Silver plan, any financial help
you currently get to lower your out-of-pocket costs will end on [51 Date].]
 I want to pick a different plan.
• You can choose a different plan between [52 Dates]. Enroll by [53 Date] for coverage
to start [54 Date].
Visit [55 Exchange website] to find other [56 Exchange] plans. Compare
plans to save money and find one that best meets your needs and budget.
Select the Plan name and ID of the plan you want to enroll in. You can also
check with [57 Issuer] to find out what other plans may be available.
[58 Important: You may be able to keep your current coverage, but [59 in
Year] it won’t be offered [60 as a Silver plan] through [61 Exchange.]
Remember, you won’t get financial help [62 to lower your out-of-pocket
costs] unless you qualify and enroll [63 in a Silver plan] through [64
Exchange].
Note: If you got financial help in [65 Year] to lower your monthly premium, you must file
federal income taxes and “reconcile” the premium tax credit you qualified for with the amount
you used during [66 Year]. If the amounts are different, it may change the amount you owe or
get back when you file your federal income taxes. To reconcile the premium tax credit, you must
complete IRS Form 8962 “Premium Tax Credit (PTC)” and include it with your federal tax
return. For more information about the premium tax credit, visit: https://www.irs.gov/affordablecare-act/individuals-and-families/the-premium-tax-credit-the-basics

We’re here to help
•
•
•
•
•

Visit [67 Exchange website], or call [68 Exchange phone number] to learn more about
[69 Exchange] and find out if you qualify for lower costs.
Call [70 Issuer] at [71 Issuer phone number] or visit [72 Issuer website].
Find in-person help from an assister, agent, or broker in your community at [73 Website].
[74 Contact an agent or broker you've worked with before [75 like Agent/broker name].
[76 Call Agent/broker phone number].]
Call [77 Exchange phone number] to get this information in an accessible format, like
large print, braille, or audio, at no cost to you.

[78 Getting help in other languages]
[79 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]

Instructions for Attachment 4 – Notice for the individual market where coverage was in a
QHP offered through the Exchange and the issuer is automatically enrolling the enrollee in
a plan under a different product offered through the Exchange
General instructions:
This notice must be used when the QHP enrollee’s current product is not available for renewal
through the Exchange (even if it remains available outside the Exchange) and the enrollee will,
consistent with State law and, if applicable, 45 CFR 155.335(j), be automatically enrolled in a
plan under a different product offered by the same QHP issuer through the Exchange. This notice
must also be used when the enrollee’s current silver level QHP is no longer available for
renewal, the enrollee’s current product no longer includes a silver level QHP available through
the Exchange, and the enrollee will, consistent with State law and, if applicable, 45 CFR
155.335(j), be automatically re-enrolled in a silver level QHP under a different product offered
by the same QHP issuer 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. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the Health
Insurance Marketplace®.”
Item 4. Enter the phrase “in your area” if non-renewing or terminating based on the fact that
there is no longer any enrollee in the plan who live, resides, or works within the product’s
service area. Otherwise, omit and skip to item 5.
Item 5. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 6. Enter the date by which a plan selection must be made to avoid automatic re-enrollment,
in format Month DD, YYYY.
Item 7. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 8. Enter the issuer name.
Item 9. 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 10.
Item 10. Enter the first day on which the current plan will no longer be available, in format
Month YYYY.
Item 11. Enter the phrase “in your area” if non-renewing or terminating based on the fact that
there is no longer any enrollee in the plan who live, resides, or works within the product’s
service area.
Item 12. If issuer will not offer the enrollee’s current product through the Exchange for the
following benefit year, or will offer the current product through the Exchange but will not offer a
Silver plan under that product and will auto-enroll the enrollee in a Silver level plan under a
different product offered through the Exchange in accordance with 45 CFR 155.335(j), include

the phrase “in [the Exchange]” and enter the Exchange name. For a Federally-facilitated
Exchange, enter “the Marketplace.” Otherwise omit and skip to item 14.
Item 13. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 14. Enter the last day on which the enrollee’s current coverage will remain in force through
the Exchange, in format Month DD, YYYY.
Item 15. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 16. 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, enter the month and year
following the discontinuance, non-renewal, or termination in format Month YYYY.
Item 17. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 18. 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) or, if such date falls within an open enrollment period, enter the end date of the
open enrollment period, in format Month DD, YYYY.
Items 19 and 20. Enter the plan name in which the enrollee will be automatically re-enrolled.
Item 21. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the beginning month of the following benefit year, in format Month YYYY. For
discontinuances, non-renewals, or terminations effective at any time other than the end of a
calendar year, enter the month following the discontinuance, non-renewal, or termination, in
format Month YYYY.
Item 22. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter the beginning month of the following benefit year. For discontinuances, nonrenewals, or terminations effective at any time other than the end of a calendar year, enter the
month following the discontinuance, non-renewal, or termination, in format Month YYYY.
Item 23. Enter the monthly premium for the enrollment group for which data are available for
the following policy year, minus the monthly amount of any advanced payments of the premium
tax credit paid on behalf of the enrollment group for which data are available.
Item 24. Enter the actual or estimated total monthly premium for the following benefit year.
Item 25. Enter the phrase “the same amount of financial help you’re getting now” if the
Exchange has not completed the annual eligibility redetermination by the time of providing the
notice. If the Exchange has completed this redetermination by the time of providing the notice,
enter the amount of advanced payments of the premium tax credit calculated from that
redetermination.
Item 26. Enter the following year, in format YYYY.
Item 27. Enter the month in which the enrollee will receive a bill for the actual monthly payment
for the following benefit year.
Item 28. Enter the benefit year from which financial information is being used to calculate the
future year estimated premium amount, in format YYYY.

Item 29. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 30. Enter current year, in format YYYY.
Item 31. Enter the most recent amount of monthly premium for the enrollment group for which
data are available for the current benefit year, minus the most recent monthly amount of any
advance payments of the premium tax credit paid on behalf of the enrollment group for which
data are available.
Item 32. Enter the most recent amount of monthly premium for the enrollment group for which
data are available for the current benefit year.
Item 33. Enter the current year monthly amount of any advance payments of the premium tax
credit paid on behalf of the enrollment group for which data are available. If the most recent
APTC paid on behalf of the enrollment group is zero, enter 0.
Item 34. List significant plan changes, including but not limited to changes in deductibles, cost
sharing, metal level, covered services, eligibility, plan formulary and provider network. For the
purpose of describing plan changes, the issuer may use the current cost-sharing reductions (CSR)
eligibility if it has not received the updated CSR eligibility from CMS. This section may also
refer to enclosed supplemental materials. Do not include the italicized instructions.
Item 35. Enter the issuer website.
Item 36. 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, enter the word “new.”
Item 37. Enter SBC web page for the applicable plan.
Item 38. 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) or, if such date falls within an open enrollment period, enter the end date of the
open enrollment period, in format Month DD, YYYY.
Item 39. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 40. Enter the date by which a plan selection must be made to avoid automatic reenrollment, in format Month DD, YYYY.
Item 41. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 42. For discontinuances, non-renewals, or terminations effective at the end of a calendar
year, enter “in” and the following benefit year, in format YYYY. For discontinuances, nonrenewals, or terminations effective at any time other than the end of a calendar year, omit.
Item 43. Include this paragraph if an enrollee's portion of premium after advanced payments of
the premium tax credit is $0 for the current benefit year. Otherwise, omit and skip to item 47.
Item 44. Enter the current year, in format YYYY.
Item 45. Enter the following year, in format YYYY.
Item 46. Enter the current year, in format YYYY.
Item 47. Enter plan name and HIOS Plan ID of plan into which the enrollee will be enrolled.

Item 48. Include this paragraph if the enrollee (except for Indian enrollees) is currently enrolled
in a Silver level QHP and will be re-enrolled into a non-Silver level QHP, consistent with 45
CFR 155.335(j). Otherwise, omit and skip to item 52.
Item 49. Enter the applicable benefit year, in format YYYY.
Item 50. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 51. Enter last day of the current policy year, in format Month DD, YYYY.
Item 52. 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 open enrollment period, enter the end
date of the open enrollment period, in format Month DD, YYYY.
Items 53 and 54. Enter the date by which a plan selection must be made and the corresponding
coverage effective date that would result in no gap in coverage between the terminating coverage
and the newly selected plan, in format Month DD, YYYY.
Item 55. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”
Item 56. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”
Item 57. Enter the issuer name.
Item 58. Include this sentence only if enrollee’s current product remains available for renewal
for the following benefit year, whether through or outside of the Exchange. Otherwise, omit and
skip to item 62.
Item 59. 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 60. 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 61. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 62. Enter the phrase “to lower your out-of-pocket costs” if you entered “as a Silver plan” in
item 60. Otherwise, omit and skip to item 64.
Item 63. Enter the phrase “in a Silver plan” if you entered “as a Silver plan” in item 60.
Otherwise, skip to item 65.
Item 64. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 65. Enter the current benefit year, in format YYYY.
Item 66. Enter the current benefit year, in format YYYY.
Item 67. Enter the Exchange website. For a Federally-facilitated Exchange, enter
“HealthCare.gov.”

Item 68. Enter the Exchange phone number. For a Federally-facilitated Exchange, enter “1-800318-2596 (TTY: 1-855-889-4325).”
Item 69. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the
Marketplace.”
Item 70. Enter the issuer name.
Item 71. Enter the issuer phone number.
Item 72. Enter the issuer website.
Item 73. Enter LocalHelp.HealthCare.gov in a State with a Federally-facilitated Exchange. In
other States, enter the appropriate website.
Item 74. Include this phrase if the enrollee has previously used an agent or broker to enroll.
Otherwise, omit and skip to item 77.
Item 75. Enter “like” followed by the name of the agent or broker the enrollee has previously
used, if known. Otherwise, omit and skip to item 77.
Item 76. Enter “Call” followed by the phone number of agent or broker the enrollee has
previously used, if known. Otherwise, omit and skip to item 77.
Item 77. Enter the Exchange phone number and the Exchange TTY number. For a Federallyfacilitated Exchange, enter “1-800-318-2596 (TTY: 1-855-889-4325).”
Item 78. Insert “Getting Help in Other Languages” if adding a tagline pursuant to item 79.
Otherwise, leave blank.
Item 79. 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 , 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 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
For QHP issuers subject to Section 1557 that are principally engaged in the provision or
administration of health-related services, health-related coverage or other health-related
coverage, all of the issuer’s operations are considered part of the health program or activity, with
limited exceptions. Consequently, a QHP issuer must comply with the nondiscrimination
requirements of Section 1557 for the issuer’s plans offered both inside and outside the
1

45 CFR 92.101.

Exchanges. A non-QHP issuer offering coverage outside the Exchanges might also be subject to
Section 1557 if any health program or activity of the issuer receives Federal financial assistance.
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 0935-1254. This information collection is used by QHP issuers in the individual market to provide
notice where coverage in a QHP offered through the Exchange and the issuer is automatically enrolling the enrollee
in a plan under a different product offered through the Exchange. The time required to complete this information
collection is estimated to average 9 hours per response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the information collection and provide the notice to
individuals. This information collection is mandatory (45 CFR 147.106). This is a third party disclosure, and the
issue of confidentiality between third parties is out of scope for the 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, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850 or [email protected], Attention:
Information Collections Clearance Officer.