Documents must show that you were denied coverage through Medicaid or CHIP. These documents must include your name and the date you were denied coverage. Documents you can submit:
Denial letter from your state Medicaid or CHIP agency that shows your name, that you were denied coverage through Medicaid or CHIP, and the date that you were denied coverage.
Letter stating your Medicaid or CHIP coverage ended that shows you used to have Medicaid or CHIP coverage and the date it ended. This letter can be from your state Medicaid or CHIP agency or from the insurance company that provided your Medicaid or CHIP benefits.
Letter from the Marketplace that says your state Medicaid or CHIP agency sent your application to the Marketplace.
Screenshot of your eligibility results from your state’s online application, if you got your denial online.
You can upload more than one document if you have multiple documents to confirm denial of Medicaid or CHIP coverage. Select the green "UPLOAD DOCUMENTS" button on the upload screen in your application to submit each document.
What if I used to have Medicaid or CHIP coverage, but don't have it anymore?
If you had Medicaid or CHIP coverage and it ended, you can submit a letter explaining that you lost Medicaid or CHIP. See above for more information.
What if I don't have any of these documents?
You can submit a letter stating that you were denied Medicaid or CHIP, and explaining the reason you can’t provide documents. Use this form, and fill out the "Denial of Medicaid or CHIP Coverage" section. When you complete the form, select "Letter of explanation" from the drop-down menu when you're on the upload documents screen in the application.