Crosswalk of Changes

Annual Eligibility Redetermination, Product Discontinuation and Renewal Notices
(CMS-10527/OMB Control Number: 0938-1254)
Summary of Changes to Information Collection Instruments
•

The following changes were made to Attachment 1: Renewal notice for the individual
market where coverage is being renewed outside the Exchange.

Section Edited
What’s changing in –
Other Changes

•

Revision (Red indicates modified or new Language)
You can review more details about your plan at [26 Issuer
website] and in your [27 Year] Summary of Benefits and
Coverage at [28 SBC web page].

Instructions for
Attachment 1 – Item
28.
Instructions for
Attachment 1 – Item
29.
Instructions for
Attachment 1 – Item
30.

Item 28. Enter the SBC webpage for the applicable plan.

Item Numbers in notice
and instructions

Updated to correspond with changes.

•

Item 29. Enter plan name.
Item 30. Enter “by” and due date for first premium for following
policy year or omit and skip to item 3130.

The following changes were made to Attachment 2: Renewal notice for the individual
market where coverage is being renewed in a QHP offered under the same product
through the Exchange.

Section Edited
What’s changing in Your new premium
What’s changing in Your new premium

Revision (Red indicates modified or new Language)
•
Starting in [9 Month], Yyour new monthly payment
(starting in [9 Month]) is estimated to be $[10 Dollar amount].
•
[21 Exchange] may contact you about other reenrollment
options unless you pick your own plan.
•
[21 For enrollees currently enrolled in a bronze level QHP
and the new plan to which the premium information above applies,
is a bronze level QHP, insert]: Important: If you currently have a
Bronze category plan and qualify for extra savings, [22 Exchange]
may enroll you in a Silver plan from [23 issuer] so you’ll get the
most help to lower your costs in [24 Year]. The Silver plan has the
same network and an equal or lower monthly payment as the new
plan to which the premium information above applies, but covers
more of your out-of-pocket costs, like copayments, coinsurance and
deductibles. Enrolling in this (or another) Silver plan may save you
thousands of dollars each year.
1

Other changes
What you need to do –
1.
What you need to do –
2. - I want to pick a
different plan.

Here are some ways to
look at other plans and
enroll: - Note:
Instructions for
Attachment 2 - Item
21.
Instructions for
Attachment 2 - Item
22.
Instructions for
Attachment 2 - Item
23.
Instructions for
Attachment 2 - Item
24.
Instructions for
Attachment 2 - Item
25.
Instructions for
Attachment 2 - Item
26.
Instructions for
Attachment 2 - Item
30.
Instructions for
Attachment 2 - Item
41.

Item Numbers in notice
and instructions

•
[25 Exchange] may contact you about [26 this and] other
reenrollment options if you don’t choose a different plan on your
own during open enrollment.
•
You can review more details about your plan at [2328 Issuer
website] and in your [2429 Year] Summary of Benefits and
Coverage at [30 SBC web page].
Review and if necessary, update your…
•
You can choose a different plan between [33 39 Dates].
Enroll by [34 40 Date] for coverage to start January 1. [41 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.]
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-careact/individuals-and-families/the-premium-tax-credit-the-basics.
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 34.
Item 22. Enter the Exchange name. For a Federally-facilitated
Exchange, enter “Marketplace.”
Item 23. Enter Issuer name.

Item 24. Enter the following year, in format YYYY

Item 25. Enter the Exchange name. For a Federally-facilitated
Exchange, enter “Marketplace.”
Item 26. Enter “this and” if the enrollee is currently enrolled in a
bronze level QHP. Otherwise, omit and skip to item 27.
Item 25. Enter SBC web page for the applicable plan.

Item 41. 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 42.
Updated to correspond with changes.

2

•

The following changes were made to Attachment 3: Discontinuation notice for the
individual market outside the Exchange and the issuer is automatically enrolling the
enrollee in a different plan outside the Exchange.
Section Edited

Box
Your new plan for Other changes
What you need to do Here are some ways to
look at other plans and
enroll:
What you need to do Here are some ways to
look at other plans and
enroll:
Instructions for
Attachment 3 - Item
31.
Instructions for
Attachment 3 - Item
41.
Item Numbers in notice
and instructions
•

Revision (Red indicates modified or new Language)
Important: Your plan will no longer be offered next year. Take…
•
You can review more details about this plan at [29 Issuer
website] and in your [30 Year] Summary of Benefits and Coverage
at [31 SBC web page].
•
Remember, you won’t get financial help unless you qualify
and enroll through [41 Exchange].
•
Remember, you won’t get financial help unless you qualify
and enroll through [41 Exchange].

Item 31. Insert SBC web page for the applicable plan.

Item 41. Enter the Exchange name. For a Federally-facilitated
Exchange, enter “Marketplace.”
Updated to correspond with changes.

The following changes were made to 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.
Section Edited

Box
Your new plan for Your new premium
What’s changing in Your new premium

Revision (Red indicates modified or new Language)
Your plan will not be offered through the [3 Exchange] [4 in your
area] next year.
•
Starting in [21 Month], Yyour new monthly payment
(starting in [21 Month]) is estimated to be: $[22 Dollar amount].
•
[33 Exchange] may contact you about other reenrollment
options unless you pick your own plan.
•
[33 For enrollees currently enrolled in a bronze level QHP,
and the new plan to which the premium information above applies,
is a bronze level QHP, insert]: Important: If you currently have a
Bronze category plan and qualify for extra savings, [34 Exchange]
may enroll you in a Silver plan from [35 issuer] so you’ll get the
most help to lower your costs in [36 Year]. The Silver plan has the
3

same network and an equal or lower monthly payment as the new
plan to which the premium information above applies, but covers
more of your out-of-pocket costs, like copayments, coinsurance and
deductibles. Enrolling in this (or another) Silver plan may save you
thousands of dollars each year.

What’s changing in –
Other Changes
What you need to do –
1.
What you need to do –
2. – I want to enroll in
this plan
What you need to do –
2. – I want to pick a
different plan

Here are some ways to
look at other plans and
enroll: Note:
Instructions for
Attachment 4 - Item
33.
Instructions for
Attachment 4 - Item
34.
Instructions for
Attachment 4 - Item
35.
Instructions for
Attachment 4 - Item
36.
Instructions for
Attachment 4 - Item
37.
Instructions for
Attachment 4 - Item
38.

•
[37 Exchange] may contact you about [38 this and] other
reenrollment options if you don’t choose a different plan on your
own during open enrollment.
•
You can review more details about this plan at [3540 Issuer
website] and in your [3641 Year] Summary of Benefits and
Coverage at [42 SBC web page].
Review and if necessary, update your…
Update your [42 Exchange] application information, and then select
[43Select [48 Plan name and ID] to enroll.
•
You can choose a different plan between [4853 Dates].
Enroll by [4954 Date] for coverage to start [5055 Date]. [56 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.]
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-careact/individuals-and-families/the-premium-tax-credit-the-basics.
Item 33. 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 34.
Item 34. Enter the Exchange name. For a Federally-facilitated
Exchange, enter “Marketplace.”
Item 35. Enter Issuer name.

Item 36. Enter the following year, in format YYYY.

Item 37. Enter the Exchange name. For a Federally-facilitated
Exchange, enter “Marketplace.”
Item 38. Enter “this and” if the enrollee is currently enrolled in a
bronze level QHP. Otherwise, omit and skip to item 39.

4

Instructions for
Attachment 4 - Item
42.
Instructions for
Attachment 4 - Item
48.
Instructions for
Attachment 4 - Item
56.

Item 42. Enter SBC web page for the applicable plan.

Item Numbers in notice
and instructions

Updated to correspond with changes.

•

Item 56. 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 57.

The following changes were made to Attachment 5: Discontinuation notice for the
individual market outside the Exchange and the issuer is not automatically enrolling
the enrollee in a different plan.
Section Edited

Box
•

Item 48. Enter plan name and HIOS Plan ID of plan into which the
enrollee will be enrolled.

Revision (Red indicates modified or new Language)
Important: Your health coverage is ending.

The following changes were made to 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
Section Edited

Box
What you need to do –
1.
What you need to do –
2. - Here are some
ways to look at other
plans and enroll:

Revision (Red indicates modified or new Language)
Important: Your health coverage is ending.
Review and if necessary, update your…
[20 Exchange] may pick a plan for you. If you don’t enroll in a plan
on your own, [21[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 [2224 Issuer] to see what other plans may be
available, including whether the plan you now have can be
purchased directly through [23 25 Issuer].
[26 Issuers on the Federally-facilitated Exchange or on a Statebased Exchange on the Federal platform, insert: If you choose a
5

plan between December 16 and January 15, the new plan will start
February 1.]

Here are some ways to
look at other plans and
enroll: - Note:
Instructions for
Attachment 6 – Item
20.
Instructions for
Attachment 6 – Item
21.
Instructions for
Attachment 6 – Item
22.
Instructions for
Attachment 6 – Item
23.
Instructions for
Attachment 6 – Item 24
and Item 25.
Instructions for
Attachment 6 – Item
26.

Item Numbers in notice
and instructions

[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 [33 Exchange].
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-careact/individuals-and-families/the-premium-tax-credit-the-basics.
ItemsItem 20 - 21. Enter the…

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.
Updated to correspond with changes.

6