Here is the list of acceptable documents. Documents must show that you lost qualifying health coverage in the past 60 days or will lose coverage in the next 60 days. These documents must include your name and the date of coverage loss.
- A letter from an insurance company, on official letterhead or stationery, including:
- A letter or premium bill from your former insurance company that shows you or your dependent’s cancellation/termination from health coverage.
- A decertification letter from your insurance company stating when coverage will no longer be offered.
- A letter from an employer, on official letterhead or stationery, that confirms one of these about you or your spouse or dependent family member:
- That your employer dropped or will drop your coverage or benefits.
- That your employer stopped or will stop contributing to your cost of coverage.
- That your employer changed or will change coverage or benefits, and your coverage will no longer be considered qualifying health coverage.
- A letter about COBRA coverage, like a letter from an employer or health insurance company that confirms these:
- Your employer’s offer of COBRA coverage along with the date this coverage would start.
- Your COBRA coverage ended or will end, or your employer stopped or will stop contributing to the cost of coverage and when.
- A health care program document, on official letterhead or stationery, including:
- A letter from a government health program, like TRICARE, Veterans Affairs (VA), Peace Corps, or Medicare, showing when coverage ended or will end.
- A letter from your state Medicaid or CHIP agency showing that your eligibility for Medicaid or CHIP was denied and when it was denied or that your Medicaid or CHIP coverage ended or will end.
- A dated copy of your military discharge document (DD214).
- A letter if you lost student health coverage, which shows when the coverage ended or will end. This should be on official letterhead or stationery.
You can also submit any of the documents in the list below. However, these documents may include only some of the information we need to confirm, so you’ll most likely need to submit more than one of these documents:
- Pay stubs, if you lost employer-sponsored coverage. You can submit:
- 2 pay stubs from the past 1-3 months, one that shows a deduction for health coverage and another which shows that the deduction ended in the past 60 days.
- If a reduction in work hours caused you to lose coverage, you can submit one previous pay stub that shows that you worked 30 or more hours and a deduction for health coverage, and a pay stub from the past 60 days that shows that you worked less than 30 hours and no deduction for health coverage.
- Document showing you lost coverage because of divorce, legal separation, custody agreements, or annulment within 60 days of submitting your application, including:
- Divorce or annulment papers that show the date responsibility ends for providing health coverage or proof that you stopped getting health coverage because of your relationship to your former spouse.
- Legal separation papers that show the date responsibility ends for providing health coverage.
- Other confirmation that you lost or will lose coverage because of divorce, legal separation, or annulment that shows the date that health coverage ends.
- Document showing you lost coverage due to death of a family member, including:
- A death certificate or public notice of death and proof that you were getting health coverage because of your relationship to the deceased person, like a letter from an insurance company or employer that shows the names of the people on the health plan.
- Other confirmation that shows you lost or will lose coverage because of the death of a spouse or other family member.
What if I'm in a plan that ended before the end of the calendar year?
If you’re losing or lost coverage from a non-calendar year plan, you can submit a dated and signed copy of written verification from an insurance agent, or a dated letter from your insurance company stating when the coverage year ends.
What if I don't have any of these documents?
You can submit a letter explaining the coverage you had, why and when you lost it or will lose it, and the reason you can't provide documents. Use this form and fill out the “Loss of Coverage” section.