Fillable Letter of Explanation to Conrm Life Events (Centers for Medicare & Medicaid Services)

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Letter of Explanation to Conrm Life Events (Centers for Medicare & Medicaid Services)

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The Letter of Explanation to Conrm Life Events (Centers for Medicare & Medicaid Services) form is 2 pages long and contains:

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File type: PDF

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Letter of Explanation to Conrm Life Events
If you get a notice from the Marketplace saying that you need to submit documents to confirm a life event,
you can upload or mail the Marketplace certain documents. If you don’t have any of these documents, you
can submit this “letter of explanation.”
To do this, save this file to your computer, fill out the section below and upload it to your Marketplace
account on HealthCare.gov. If you need more room, you can continue on a blank sheet of paper.
On HealthCare.gov, select “Letter of explanation” from the drop-down menu of document types. Or, you can
mail it to the Marketplace with your printed bar code page from your eligibility notice. Here’s the mailing address:
Health Insurance Marketplace, Attn: Supporting Documentation, 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.)
Loss of Coverage
What kind of coverage did you/do you have?
When did you/will you lose your coverage?
____ / ____ / ______
MM DD YYYY
Why are you losing your coverage?
Why can’t you submit the requested documents?
Move
Check this box if you had health coverage at least one day during the 60 days before your move.
Check this box if you moved from a foreign country or U.S. territory.
What’s your old address?
When did you move?
____ / ____ / ______
MM DD YYYY
What’s your new address?
Why can’t you submit the requested documents?
Marriage
Check this box if you or your spouse had health coverage at least one day during the 60 days before getting married.
Who was married? List their names.
When were these people married?
____ / ____ / ______
MM DD YYYY
Is there any other information you’d like to include about this marriage?
Why can’t you submit the requested documents?
Denial of Medicaid or CHIP Coverage
Who was denied coverage through Medicaid or CHIP? List names of everyone on
your application who was denied.
When were these people denied coverage?
____ / ____ / ______
MM DD YYYY
Why can’t you submit the requested documents?
Adoption, Foster Care Placement, or Court Order
Who was adopted, placed in foster care, or became a dependent through a court order?
List names of everyone on your application who this applies to.
When did this event happen?
____ / ____ / ______
MM DD YYYY
Is there any other information you’d like to include about the adoption, foster care placement, or court order?
Why can’t you submit the requested documents?
You have the right to get Marketplace information in an accessible format, like large print, Braille, or audio. You also have the
right to file a complaint if you feel you’ve been discriminated against. Visit CMS.gov/about-cms/agency-information/about
website/cmsnondiscriminationnotice.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.
CMS Product No. 12008
Revised September 2019
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Letter of Explanation to Conrm Life Events (Centers for Medicare & Medicaid Services)

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Completed 19 July 2020

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