Fillable Letter of Explanation to Conrm Application Information (Centers for Medicare & Medicaid Services)

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Letter of Explanation to Conrm Application Information (Centers for Medicare & Medicaid Services)

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Letter of Explanation to Conrm Application
Information
If you provide information on your Marketplace application that doesn’t match our records, you’ll need to
submit documents to conrm your information. If you don’t have any of these documents, you can submit
this “letter of explanation,” in some cases.
To do this, save this le to your computer, ll out the section below, and upload it to your account on
HealthCare.gov. If you need more room, you can continue on a blank sheet of paper.
On HealthCare.gov, select “other” from the drop-down menu of document types. Or, you can mail a copy
to the Marketplace. Include the printed bar code page from your Marketplace notice. Here’s the mailing
address: Health Insurance Marketplace, Attn: Coverage Processing, 465 Industrial Blvd., London, KY
40750-0001. Visit HealthCare.gov/submit-documents for more information.
Your Name
Your Application ID
(You only need to write your application ID if you’re mailing this document. Your application ID is at
the top of your notice near your mailing address.)
____ / ____ / ______
Conrming You Don’t Have Coverage Through Medicare
Check this box if you’re currently enrolled in Medicare Part B
(Medical Insurance), but you’re not eligible for premium-free
Medicare Part A (Hospital Insurance).
When did your Part B coverage start?
MM
____ / ____ / ______
____ / ____ / ______
DD YYYY
Tell us why you’re not eligible for Part A:
OR
Check this box if you had Part A coverage, but are no longer enrolled.
When did your Part A coverage end?
MM DD YYYY
Tell us about your recent health coverage, including that you no longer have coverage through Medicare Part A:
OR
Check this box if you had Medicare disability coverage, but are no longer
enrolled.
When did your Medicare disability
coverage end?
MM DD YYYY
CMS Product No. 12021
Revised October 2019
Conrming You Don’t Have Coverage Through TRICARE
Tell us about your recent health coverage, including when your TRICARE ended:
Check this box if you were never enrolled in TRICARE.
Conrming You Don’t Have Coverage Through the Peace Corps
Tell us about your recent health coverage, including that you’re not eligible for or enrolled in health coverage through the Peace Corps:
Check this box if you were never eligible for or enrolled in coverage through the Peace Corps.
Conrming You Don’t Have Coverage Through the Department of Veterans Aairs (VA)
Tell us about your recent health coverage, including that you’re not enrolled in health coverage through the VA:
Check this box if you were never eligible for or enrolled in coverage through the VA.
Conrming You’re Not Incarcerated
Tell us why you can’t submit the requested documents to conrm you’re not incarcerated:
You have the right to get Marketplace information in an accessible format, like large print, Braille, or audio. You also have the right to le a
complaint if you feel you’ve been discriminated against. Visit CMS.gov/about-cms/agency-information/aboutwebsite/cmsnondiscrimina-
tionnotice.html, or call the Marketplace Call Center at 1-800-318-2596 for more information. TTY users can call 1-855-889-4325.
Paid for by the Department of Health & Human Services.
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Letter of Explanation to Conrm Application Information (Centers for Medicare & Medicaid Services)

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Completed 19 July 2020

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