NOTICE: Important Information about Your Health Coverage for 2017 You Must Choose a New Plan for Next Year

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1 Maryland Health Connection P.O. Box 857 Lanham, MD <Date Stamp> <Address> NOTICE: Important Information about Your Health Coverage for 2017 You Must Choose a New Plan for Next Year Dear <<Individual Name>>, <Conditional: display for the original 1311 notice> URGENT: Your health coverage is at risk. Take action by December 15, or you won t have health coverage in 2017 and you may have to pay a penalty of $695 or more when you file your taxes. Why am I getting this letter? The health insurance coverage for you or someone in your household is ending December 31. Please see below for additional explanation about why your coverage is ending. You must enroll in a new plan by December 15, or you won t have coverage as of January 1. Read this letter carefully and review your options. Also, make sure to update your information with Maryland Health Connection. You can choose a new plan between November 1 and January 31. To make sure you don t have a gap in your coverage, enroll in a new plan by December 15. Please read this entire notice. The YOUR NEW PLAN AND COST INFORMATION section below has important information about your eligibility for coverage for 2017, your household s eligibility for financial assistance, and the next steps you need to take for your coverage for next year. If anyone in your household is enrolled in Medicaid or the Maryland Children s Health Program (MCHP), they will get a separate notice before their renewal period. Open Enrollment is from November 1, 2016 to January 31, During Open Enrollment, you may: Enroll in a medical and/or dental plan; Change your current coverage to a different plan; Change the members of your household on your existing coverage; or Tell us of any change in income, household size or other information that you have not reported that may affect your eligibility (NOTE: Changes must be reported within 30 days of the change).

2 <Conditional: display for applications for which renewal notice for this plan year was already sent>> Why am I getting this letter? You are receiving this letter because you made changes to your current enrollment after we sent you the notice Important Information about Your Health Coverage for Because you ve updated your information, we have reviewed your eligibility again for next year. The current health insurance coverage for you or someone in your household is ending December 31. Visit MarylandHealthConnection.gov if you need to make additional changes to your information and shop for a new plan for Any changes to your information or plan made by December 15 will be effective January 1. You can still make changes by January 15 to be effective February 1. Please read this entire notice. The YOUR NEW PLAN AND COST INFORMATION section below has important information about your eligibility for coverage for 2017, your household s eligibility for financial assistance, and the next steps you need to take for your coverage for next year. If anyone in your household is enrolled in Medicaid or the Maryland Children s Health Program (MCHP), they will get a separate notice before their renewal period. Open Enrollment is from November 1, 2016 to January 31, During Open Enrollment, you may: Enroll in a medical and/or dental plan; Change your current coverage to a different plan; Change the members of your household on your existing coverage; or Tell us of any change in income, household size or other information that you have not reported that may affect your eligibility (NOTE: Changes must be reported within 30 days of the change). <Conditional: display if household member had UHC plan in 2016> IMPORTANT: You will need to choose a new health insurance company and a new health plan to start January 1, 2017, because United Healthcare will no longer be offering plans through Maryland Health Connection. United Healthcare will also send you a letter about your plan ending. If you would like to enroll in dental coverage, you must also select a dental plan for If you do nothing, you will not have coverage after December 31. <Conditional: display if primary is deceased> IMPORTANT: You will need to renew your health coverage or select a new plan to start January 1, 2017, because our records indicate that the primary enrollee in your 2016 coverage is deceased and we cannot automatically renew your household s coverage. If other members of the household want to enroll in coverage for 2017, they should create a new application for 2017 through Maryland Health Connection. If you would like to enroll in dental coverage, you must also select a dental plan for If you do nothing, you will not have coverage after December 31.

3 What you need to do 1. Make any updates to your Maryland Health Connection application now. Review your information at MarylandHealthConnection.gov carefully, and use the Change My Information button if anything has changed. Updating your household and income information makes sure you are receiving the right amount of financial help, and could lower your monthly insurance bill. 2. Choose a new plan for Review the section YOUR NEW PLAN AND COST INFORMATION below for specific instructions for your household. You can shop for a new plan at MarylandHealthConnection.gov. Maryland Health Connection is the only place you can get financial help to lower your insurance costs. 3. Get help understanding this information. If you re not sure what this letter is saying about your health coverage or what steps you need to take, call us at (TTY: ), or find local help at MarylandHealthConnection.gov/get-help-enrolling/. YOUR NEW PLAN AND COST INFORMATION Your Medical Coverage This Year (2016) Next Year (2017) Covered Individual(s): <<FNMNLNS>> We could not renew <<FNMNLNS>> your coverage for Plan Information You must enroll in a plan by December 15, <<Carrier Name>> <Plan Name 2016> Coverage Date Coverage ends December 31, 2016 Monthly Premium << Enrollee 1 Health Insurance Plan Premium>> <Conditional: display if financial assistance eligibility is determined> Financial Assistance Eligibility This Year (2016) Next Year (2017) Advanced Premium Tax Credit (Monthly) Eligible for Cost-Sharing Reduction? $<Current Total APTC> <Yes/No> $<New Total APTC> <Yes/No> <Conditional: display if individuals are found eligible for APTC> Eligibility for a Tax Credit for <<Coverage Year>> Based on a household size of <<household size>> and your last confirmed income of <<Individual HH Income>>, you are eligible to receive up to $<New Total APTC> in premium tax credits per month to apply toward your Qualified Health Plan (QHP) premium in <<Coverage Year>>.

4 The advanced premium tax credit (APTC) is a federal tax credit that helps make health insurance affordable. You can choose to apply anywhere from $0 to the full monthly amount toward your insurance bills now, or when you file your federal income taxes for <<Coverage Year>>. If the information we have on your household size or income is not correct, you should report a change in your information using the steps below under How do I change plans or report a change in my information? <Conditional: display if individuals are determined eligible for CSR> Eligibility for Cost-Sharing Reductions You are eligible for cost-sharing reductions (CSR), which means you could pay less out of pocket for costs like your deductible or copay. You can only get these savings if you choose a Silver-level plan. If you are eligible for a cost-sharing reduction and are not enrolled in a Silver-level plan, you will miss out on this benefit. <Conditional: display if fail to authorize, fail to file/reconcile, otherwise fail to determine financial assistance eligibility> Financial Assistance Eligibility This Year (2016) Next Year (2017) Advanced Premium Tax Credit (Monthly) Eligible for Cost-Sharing Reduction? $<Current Total APTC> <Yes/No> We could not determine your eligibility for financial assistance. Additional information below. <Conditional: display if enrolled in SADP in 2016 and SADP 2017 crosswalk is available> Your Dental Coverage This Year (2016) Next Year (2017) Covered Individual(s): <<FNMNLNS>> <<FNMNLNS>> <<FNMNLNS>> <<FNMNLNS>> Plan Information <<Carrier Name>> <Plan Name 2016> <Plan Name 2017> Coverage Date Coverage ends December 31, 2016 Coverage begins January 1, 2017 Monthly Premium << Enrollee 1 Health Insurance Plan Premium>> << Enrollee 1 Health Insurance Plan Premium>> <Conditional: display if enrolled in SADP and SADP crosswalk failed> Your Dental Coverage This Year (2016) Next Year (2017) Covered Individual(s): <<FNMNLNS>> We could not renew your <<FNMNLNS>> coverage for You Plan Information <<Carrier Name>> <Plan Name 2016> must enroll in a plan by December 15, 2016.

5 Coverage Date Monthly Premium Coverage ends December 31, 2016 << Enrollee 1 Health Insurance Plan Premium>> <Conditional: display if individuals are determined eligible for Medicaid or CHIP> Eligibility for Medicaid or MCHP Based on information in your latest Maryland Health Connection application, the following individuals have been determined eligible for Medicaid or MCHP: <<Medicaid Placeholder>> <<Individuals Name>> <<CHIP Placeholder>> <<Individuals Name>> Begin Date <<Begin Date>> Begin Date <<Begin Date>> Visit MarylandHealthConnection.gov or contact us to enroll these household members in Medicaid or to select a qualified health plan (without financial assistance). A person who is eligible for Medicaid/MCHP cannot receive other forms of financial assistance (tax credits and cost-sharing reductions). <Conditional: display if an individual is not eligible for QHP or financial assistance in the household > IMPORTANT: Based on information in your latest Maryland Health Connection application, the following individuals are no longer eligible to be part of the household s Qualified Health Plan (QHP) for 2017 or are no longer eligible for financial assistance. If any member is not eligible to part of the household s QHP, they may qualify for coverage on their own plan for Denied Individuals Name Program Reason Household Size <<INDIVIDUALS NAME>> <<INDIVIDUALS NAME>> ALL <QHP> Individual failed to meet citizenship or alien status for <QHP> Aged out of policy Income Standard Household Income <Conditional: display if a household member has aged out of QHP for upcoming year> IMPORTANT: <AGED OUT FNLN> has turned 26 and is no longer eligible to be covered on your plan. <AGED OUT FNLN> s coverage will automatically be terminated on December 31, < AGED OUT FNLN> must apply for a separate plan by December 15, 2016 to avoid

6 a gap in coverage. As long as < AGED OUT FNLN> selects a new plan by that date, the new plan will be effective January 1, <Conditional: display if a household member has aged out of Catastrophic Plan for upcoming year> IMPORTANT: <CAT AGE OUT FNLN> is covered by a catastrophic plan this year. However, <CAT AGE OUT FNLN> has turned 30 years old and is not eligible for catastrophic coverage next year without a hardship exemption. For more information about the hardship exemption, visit MarylandHealthConnection.gov/exemptions-penalty/. To avoid a gap in coverage, Maryland Health Connection has renewed <CAT AGE OUT FNLN> into a 2017 plan selected by <CAT AGE OUT FNLN> s carrier. <CAT AGE OUT FNLN> has until December 15, 2016 to select a different plan that starts January 1, <Conditional: display if authorizations to retrieve tax return information, via Yearly Renewal Confirmation, has expired and/or user never authorized Maryland Health Connection to access the tax return for renewal> IMPORTANT: In a prior year or years, advance payments of the premium tax credit (APTC) were made to your health insurance company to reduce your premium. We have determined that you are not eligible for APTC or cost-sharing reductions for your coverage in 2017 because of one of the following reasons: We can t tell if a federal income tax return was filed for this household to reconcile the tax credits used to lower plan premium costs during any previous year(s) that your household received APTC; or When you applied for coverage, you chose not to allow Maryland Health Connection to use income data, including information from tax returns, to help renew your eligibility. It s important for you to take the steps below, or you will not be eligible for financial help with your health coverage and will pay more up-front in 2017: 1. If you received APTC in 2016 or 2015, but a tax return with Form 8962 wasn t filed for your household in any year you received APTC, you must file a federal income tax return with IRS Form 8962 Premium Tax Credit as soon as possible, even if you don t usually have to file taxes or if you requested an extension to file your tax return. You need to file BOTH a tax return AND Form 8962 to remain eligible for financial help. 2. After you file your tax return AND Form 8962 for any year that you received APTC, visit MarylandHealthConnection.gov and log into your account to update your application information by following the steps under How do I change plans or report a change in my information? After you have submitted the required documents to IRS, be sure to check the box telling us you filed your tax return and you reconciled your premium tax credits. You should have received a Form 1095-A, Health Insurance Marketplace Statement to help fill out Form 8962 and file your tax return for any previous year(s) that your household received APTC. If you don t have a copy of Form 1095-A, visit MarylandHealthConnection.gov and check your account s My Inbox, or call Maryland Health Connection at (TTY: ). If you have questions about your household s tax filing status, use the Interactive Tax Assistant ( or call the IRS Telephone Assistance

7 for Individuals at In many cases, filing your tax return electronically is free, can help avoid mistakes, and will help you find credits and deductions that may be available to you. For more information about Free File and e-file, please visit IRS.gov and search for free file or e-file. If you filed a tax return but didn t include Form 8962, you may need to file an amendment to your tax return (Form 1040X). To learn more, call the IRS Telephone Assistance for Individuals. If you are not eligible for financial help in 2017 because you chose not to allow Maryland Health Connection to use income data to help renew your eligibility, and you would like to change this setting and become eligible for financial help, you can do so online using the steps under How do I change plans or report a change in my information? You must update your application by December 15, 2016 to help avoid a gap in help with costs of your Maryland Health Connection coverage and for covered services (if applicable). How Maryland Health Connection Made Its Decision Maryland Health Connection made the eligibility determination above using the regulations found at 45 CFR If you disagree with our decisions about your financial assistance or eligibility for a qualified health plan, you have the right to file an appeal as explained in the page attached. You may need to provide more information to continue your eligibility for longer than ninetyfive (95) days. You will be told in another notice ( Additional Verification Required ) if you need to give us more information. If you do not respond to that notice, or if you cannot verify the information you provided during the application process, your coverage may change or end. Dental insurance is available through Maryland Health Connection If your health insurance does not offer dental coverage, you can buy a dental plan through Maryland Health Connection. All qualified health plans offered through Maryland Health Connection already include basic dental coverage for children. When will my new plan start? If you select a new plan by December 15, 2016, your new coverage will begin January 1, If you select a new plan between December 16, 2016 and January 15, 2017, your new coverage will begin February 1, If you select a new plan between January 15, 2017 and January 31, 2017 (the end of Open Enrollment), your new coverage will begin March 1, How do I change plans or report a change in my information? Log into your account at MarylandHealthConnection.gov, and use the Change My Information quick link. You should review the information carefully, make any changes needed, and then proceed through the rest of the application to complete the enrollment process. You should make any changes by December 15 for them to be applied effective January 1. You may report additional changes or change your 2017 plan between November 1, 2016 and January 31, (If any family members are covered through Medicaid be sure to state in your application that they are applying for health coverage so that their coverage is not cancelled.)

8 If you need to report a change in your information, you should do so as soon as possible. It is important to make sure your household and income information are accurate, and to report any changes within 30 days, so that you get the right amount of financial assistance. If the information that Maryland Health Connection has is not correct, such as household income and household size, you may owe more taxes or get a smaller refund when you file your next federal tax return. Consider these things when choosing a plan: Premium The amount you pay for health coverage may change. Insurance companies rates may increase or decrease each year. Payment Assistance The amount of APTC you are eligible for can be used now to lower your monthly insurance premium, or you can get this money when you file your tax return for This notice tells you the amount of payment assistance you will receive next year based on your current information. Discounts for Out-of-Pocket Costs If you are eligible for cost-sharing reductions, you will pay lower out-of-pocket costs when you use a provider. You can only get the special discounts if your income qualifies and you choose a Silver-level health plan. If you are eligible for a cost-sharing reduction and are not enrolled in a Silver-level plan, you will miss out on this benefit. Plan Benefits There may be changes to your plan benefits, including your copayments, coinsurance and deductibles. Your insurance company will notify you of these changes. Plan Options There may be new insurance plans and new insurance companies available through Maryland Health Connection for You may want to explore all of your options. On November 1, 2017, you will be able to see those new options at MarylandHealthConnection.gov. Questions or need help? Maryland Health Connection wants to make choosing health coverage as easy as possible. You can get free help understanding this information or making any changes to your plan. You may also get free, in-person help from an authorized insurance broker, connector entity navigator or by calling us at (TTY: ). You can also find local help at MarylandHealthConnection.gov/get-help-enrolling/. If you have a disability, you may request and receive a reasonable accommodation or special help from Maryland Health Connection when it is necessary to allow you to apply for and receive services through Maryland Health Connection. Sincerely, Maryland Health Connection

9 Appeal Rights and Deadlines You can appeal any decision you receive from Maryland Health Connection. You or your authorized representative has 90 days from the date of this notice to ask for a hearing. An authorized representative is someone who you choose to act on your behalf with Maryland Health Connection, like a family member or other trusted person. Some authorized representatives may have legal authority to act on your behalf. To ask for a hearing: By Mail: Complete the Request for Fair Hearing form or write a request to: Maryland Health Connection or: Office of Administrative Hearings P.O. Box Gilroy Road Lanham, MD Hunt Valley, MD By Complete and scan the Request for Fair Hearing form or write an to: MHBE.Appeals@Maryland.gov By Phone: Call Maryland Health Connection at (TTY: ). *Please include your Person ID listed at the top of this notice on all requests. If you disagree with our decision and want to speak to someone about it, or if you need help asking for a hearing, call (TTY: ) or visit a local Department of Health, local Department of Social Services, or regional Connector Entity. If you appeal our decision, you will have a hearing. A hearing is a meeting between you, someone from Maryland Health Connection and a hearing officer. You can talk to them about why you think we made a mistake. To prepare for your hearing: You can bring a friend, relative, witness or lawyer to the hearing if you want. You should bring any documents or information you need to help us understand your concerns. You may review our documents regarding your eligibility at any time. For Medicaid, MCHP or MCHP Premium eligibility: If you have Medicaid or MCHP Premium, you might be eligible to keep your current health coverage if you appeal within 10 days of this notice. Call (TTY: ) to learn more. If you continue to receive benefits and you lose your appeal, you may have to pay back the benefits you received. The result of your appeal could change what health coverage you or others in your household qualify for. For Qualified Health Plan eligibility: If you have been determined eligible to enroll in a qualified health plan and you appeal within 90 days of this notice, you can proceed with the eligibility process. This includes enrolling in a qualified health plan and receiving any applicable financial assistance that you are currently eligible for. The result of your appeal could change what health coverage you or others in your household qualify for. For assistance with preparing an appeal of your denial of enrollment in a qualified health plan or eligibility for an advanced premium tax credit or cost-sharing reductions, you can contact the Office of the Attorney General s Health Education and Advocacy Unit online at or at or toll free at The HEAU can assist you but cannot represent you at the hearing.

10 REQUEST FOR FAIR HEARING Fill out this form ONLY if you disagree with Maryland Health Connection s decision. If you need help completing this form, call (TTY: ). 1. Tell us who you are. Fill in the blanks in this box and complete boxes 2-3. Please print clearly. Name: Date of Birth Address: City: State: Zip Code: Phone Number: ( ) Person ID: 2. What are the reasons you want a hearing? Please select one. I was not allowed to apply for coverage through Maryland Health Connection. My application was wrongly denied for (If you checked here, please select from below): Medicaid Maryland Children s Health Program (MCHP) or MCHP Premium Qualified Health Plan coverage through Maryland Health Connection Financial assistance with a Qualified Health Plan (Advanced Premium Tax Credit or Cost-sharing Reduction) I do not agree with the amount of my monthly premium tax subsidy (Advanced Premium Tax Credit) and/or the amount I have to pay out-of-pocket (Cost-sharing Reduction). Other If you received a notice about this, what is the date on the notice? Why do you want a hearing? Please tell us what happened. 3. FOR MEDICAID, MCHP OR MCHP PREMIUM ELIGIBILITY I understand that if I am currently receiving Medicaid/MCHP Premium, and I ask for a hearing within 10 days from the date of the notice, I can continue to receive those benefits while I wait for my hearing unless my benefits period ends. I also understand that I may have to pay back those benefits if I lose my appeal. Check and sign here if you do not want benefits while you wait for your hearing. Signature Date 4. FOR QUALIFIED HEALTH PLAN ELIGIBILITY I understand if I ask for a hearing within 90 days from the date of the notice, I can still enroll in a qualified health plan and receive any financial assistance I am currently eligible for. The result of my appeal can change what coverage I qualify for. Depending on the result of my appeal, I may have to pay back any tax subsidies I receive to the Internal Revenue Service. Check and sign here if you do not want benefits while you wait for your hearing. Signature Date