Submit a copy of one of the following documents.
- Certificate of coverage or letter from the health plan issuer showing the end date of coverage.
- Government-issued document showing date of termination of coverage or ineligibility to program.
- Employer statement indicating no offer of affordable minimum value employer-sponsored coverage.
- Self-attestation, where the individual is unable to provide any of the above documents.
To show lack of Medicare eligibility or enrollment:
- Letter or statement from Medicare or the Social Security Administration stating that you or your family members are:
- Not eligible for or enrolled in premium-free Medicare Part A; or
- Eligible for (but not enrolled in) Part A coverage that requires premium payments. Important: A Social Security document that shows you don’t pay a premium for “Medical Insurance” refers to Part B. It’s not acceptable for verifying eligibility for Part A; or
- No longer eligible for Social Security Disability Insurance (SSDI) benefits, and your coverage has ended or will end in the next 90 days.
- If you are unable to obtain this letter, you may complete and submit an Attestation of Medicare Eligibility and Enrollment Status form.