CMS-10527 Discontinuation without auto enrollment (QHP)

OMB Control No.: 0938-1254 Expiration Date: XX/XX/XXXX

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

[1 Date]

[2 [First Name][Last Name] [Address line 1]

[Address line 2] [City][State][Zip]]

Important: Your health coverage is ending. Update your [3 Exchange] application and pick a different plan by [4 Date], or you may not have health coverage in [5 Year].

Thank you for choosing [6 Issuer] for your health care needs. [7 We’re here to help you prepare for Open Enrollment.]

Why am I getting this letter?

Starting [8 Date], we won’t offer your current health coverage [9 in your area] [10 through the Exchange]. The last day of your current [11 Exchange] coverage is [12 Date].

Review your coverage options and pick a different plan between [13 Dates]. Enroll in a different plan by [14 Date] to avoid a gap in your coverage. If you don’t have health coverage, you’ll have to pay for all of your health care.

What should I do next?

1. Update your [15 Exchange] application by [16 Date].

Review your [17 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 in [18 Year] than you’re getting now. This could mean you’ll pay a lower monthly premium amount or lower out- of-pocket costs (like deductibles, copayments, and coinsurance). Plus, you might not owe money when you file your taxes.

[19 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 [20 Year]. You must update your application to qualify for a

$0 monthly premium amount in [21 Next Year]. Depending on your updated information, your [22 Next Year] monthly premium amount could still be higher than it was in [23 Current Year] if [24 Exchange] automatically enrolls you in a plan it picks for you.

2. Choose a different plan.

• Visit [25 Exchange website] to find other [26 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.

If you don’t enroll in a plan on your own, [27 Exchange] may automatically enroll you in one.

• Check with [28 Issuer] to find out what other plans may be available, and if you can purchase the plan you have now directly through [29 Issuer].

[30 Important: You may be able to keep your current coverage, but in [31 Year], it won’t be offered [32 as a Silver plan] [33 through the Exchange]]. Remember, you won’t get financial help [34 to lower your out-of-pocket costs] unless you qualify and enroll [35 in a Silver plan] through [36 Exchange].

Note: If you got financial help in [37 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 [38 Year]. If the amounts are different, it may change the amount of money 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/affordable-care-act/individuals-and- families/the-premium-tax-credit-the-basics

We’re here to help

• Visit [39 Exchange website], or call [40 Exchange phone number] to learn more about [41 Exchange] and find out if you qualify for lower costs.

• Call [42 Issuer] at [43 Issuer phone number] or visit [44 Issuer website].

• Find in-person help from an assister, agent, or broker in your community at [45 Website].

• [46 Contact an agent or broker you’ve worked with before [47 like Agent/broker name]. [48 Call Agent/broker phone number].]

• Call [49 Exchange phone number] for a reasonable accommodation to get this information in an accessible format, like large print, braille, or audio, at no cost to you.

[50 Getting help in other languages]

[51 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 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

General instructions:

This notice must be used when the QHP enrollee’s product is not available for renewal through or outside the Exchange and the issuer is not automatically enrolling the enrollee in a different plan through the Exchange. This includes non-renewals or terminations based on a product discontinuation or there no longer being any enrollee in the plan who lives, resides or works within the product’s service area. This notice must also be used when the QHP enrollee’s current product is not available for renewal through the Exchange but remains available for renewal outside the Exchange, and the issuer no longer has plans available for re-enrollment 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. 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), in order to avoid a gap in coverage, in format Month DD, YYYY.

Item 5. For discontinuances, non-renewals, or terminations effective at the end of a calendar year, enter the following 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, in format Month YYYY.

Item 6. Enter the issuer name.

Item 7. 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 8. Item 8. For discontinuances, non-renewals, or terminations effective at the end of a calendar year, enter the following 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, in format Month YYYY.

Item 9. Enter the phrase “in your area” if non-renewing or terminating based on the fact that there is no longer any enrollee under the plan who lives, resides, or works in the product’s service area. Otherwise, omit and skip to item 10.

Item 10. Include this phrase if issuer will not offer the enrollee’s current product through the Exchange for the following benefit year (even if the product remains available for renewal outside the Exchange). In such cases, for a Federally-facilitated Exchange, enter “the Health Insurance Marketplace^®.” Otherwise omit and skip to item 11.

Item 11. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the

Marketplace.” Note that if Item 10 isn’t included, enter “the Health Insurance Marketplace^®. (The first instance is the full name, and subsequent references is “Marketplace”.)

Item 12. Enter the last day on which the enrollee’s current coverage will remain in force through the Exchange, in format Month DD, YYYY.

Item 13. 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 annual open enrollment period, enter the beginning and end date of the open enrollment period, in format Month DD, YYYY.

Item 14. 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), to avoid a gap in coverage, in format Month DD, YYYY.

Item 15. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.” Item 16. Enter the date by which a plan selection must be made to avoid automatic re- enrollment, in format Month DD, YYYY.

Item 17. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.” Item 18. 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 19. Include this paragraph if an enrollee's portion of premium after advanced payments of the premium tax credit in the current benefit year is $0. Otherwise, omit and skip to item 25.

Item 20. Enter the current year, in format YYYY. Item 21. Enter the following year, in format YYYY Item 22. Enter the following year, in format YYYY Item 23. Enter the current year, in format YYYY

Item 24. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”.

Item 25. Enter the Exchange website. For a Federally-facilitated Exchange, enter “HealthCare.gov.”

Item 26. Enter the Exchange name. For a Federally-facilitated Exchange, enter “Marketplace.”

Item 27. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the Marketplace.”

Item 28 and Item 29. Enter the issuer name.

Item 30. Include this sentence only if the enrollee’s current product remains available for renewal for the following benefit year, whether through or outside the Exchange. Otherwise, omit and skip to item 34.

Item 31. 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 32. 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 33. Enter the word “through” followed by the Exchange name if either the words “as a

Silver” plan were entered in item 32 or the enrollee’s current product remains available outside the Exchange, but no longer remains available for renewal through the Exchange. In this case, enter the Exchange name. For a Federally-facilitated Exchange, enter “the Marketplace.”

Item 34. Enter the phrase “to lower your out-of-pocket costs” if the words “as a Silver plan” were entered in item 32. Otherwise, omit and skip to item 35.

Item 35. Enter the phrase “in a Silver plan” if you entered “as a Silver plan” in item 32. Otherwise, omit and skip to item 36.

Item 36. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the Marketplace.”

Item 37. Enter the current benefit year, in format YYYY.

Item 38. Enter the current benefit year, in format YYYY.

Item 39. Enter the Exchange website. For a Federally-facilitated Exchange, enter “HealthCare.gov.”

Item 40. Enter the Exchange phone number. For a Federally-facilitated Exchange, enter “1-800- 318-2596 (TTY: 1-855-889-4325).”

Item 41. Enter the Exchange name. For a Federally-facilitated Exchange, enter “the Marketplace.”

Item 42. Enter issuer name.

Item 43. Enter issuer phone number.

Item 44. Enter issuer website.

Item 45. Enter LocalHelp.HealthCare.gov in a State with a Federally-facilitated Exchange. In other States, enter the appropriate website.

Item 46. Include this phrase if the enrollee has previously used an agent or broker to enroll. Otherwise, omit and skip to item 49.

Item 47. Enter “like” followed by the name of the agent or broker the enrollee has previously used, if known. Otherwise, omit and skip to item 49.

Item 48. Enter “Call” followed by the phone number of agent or broker the enrollee has previously used, if known. Otherwise, omit and skip to item 49.

Item 49. Enter the Exchange phone number and Exchange TTY number. For a Federally- facilitated Exchange, enter “1-800-318-2596 (TTY: 1-855-889-4325).”

Item 50. Insert “Getting Help in Other Languages” if adding a tagline pursuant to instruction 51. Otherwise, leave blank.

Item 51. Insert a nondiscrimination notice and taglines consistent with any State or Federal requirements, including Section 1557 of the Patient Protection and Affordable Care Act (Section 1557). If there are no such applicable nondiscrimination 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 subject to language access standards under applicable Federal or State law, including section 1557.

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 is being discontinued was in a QHP offered through the Exchange and the issuer is not automatically enrolling the enrollee in a different plan. The time required to complete this information collection is estimated to average 5.5 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 Russell.tipps@cms.hhs.gov, Attention: Information Collections Clearance Officer.