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Documents needed to confirm your eligibility for a Qualified Health Plan (QHP)

The links below highlight the documents needed to support your application and confirm eligibility:

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Proof

Qualifying Life Event for Special Enrollment

To be eligible for a Special Enrollment Period, you must have a Qualifying Life Event. If you received a letter from us asking you to verify your Qualifying Life Event, please select the applicable event below for more information on how to confirm your Qualifying Life Event and complete your Special Enrollment.

Quality Life Event

Provide a coverage termination letter from employer, HR department, or healthcare coverage administrator of your terminated coverage. Termination letters must include:
  • Your first and last name
  • An insurance coverage end date that happened or will happen within 60 days of your Access Health CT application date.
  • The last day of coverage in the termination letter must be the same as the coverage end date you list on your application.
  • Name of employer or healthcare coverage administrator
  • Name and signature of authorized person issuing the letter
Please note: If your coverage termination letter says that you did not pay your premiums or that you chose to terminate your coverage, you will not be eligible for Special Enrollment.
A piece of mail demonstrating your move to Connecticut:
  • Proof of your address change from another state
  • A recent utility bill from your previous address AND a utility bill from your new Connecticut residence (2 documents)
  • If moving from another U.S. state, proof of minimum essential coverage for at least one day during the 60 days before your move is required. This is not required if you are moving from another country.
  • A letter of Certification of Pregnancy
  • A copy of adoption confirmation documents
  • A copy of foster care confirmation documents

Quality Life Event 2

Gain of Health Reimbursement Arrangement (HRA) or Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) or a change in employer contributions to a HRA or QSEHRA

Provide the letter from your employer, HR department, or healthcare coverage administrator that explains the gain of Health Reimbursement Arrangement (HRA) or Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) or a change in employer contributions to a HRA or QSEHRA.
The letter must include:
  • Your first and last name
  • Name of employer
  • Name and signature of authorized person issuing the letter
  • Date of eligibility or change in contribution
A copy of your marriage license/certificate AND proof of minimum essential coverage for one day during the 60 days before your marriage (either spouse)
  • Letter of attestation of decrease in household income [PDF]
  • Proof of minimum essential coverage that was not obtained through Access Health CT within 60 days of the decrease in household income.
You may need one or more of these documents, to confirm lawful presence/immigration status:
  • Permanent Resident Card (“Green Card”, I-551)
  • Temporary I-551 Stamp (on passport or I-94, I-94A)
  • Immigrant Visa (with temporary I-551 language)
  • Employment Authorization Card (EAD or I-766)
  • Arrival/Departure Record (I-94 or I-94A)
  • Arrival/Departure Record in foreign passport (I-94)
  • Unexpired foreign passport
  • Country of issuance Reentry Permit (I-327)
  • Refugee travel document (I-571)
  • Certificate of Eligibility for Nonimmigrant (F-1) Student Status (I-20)
  • Certificate of Eligibility for Exchange Visitor (J-1) Status (DS2019)
  • Notice of Action (I-797)

How to Submit Documents

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Certification of Pregnancy Sample
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Sample Employer Statement SP
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Sample Attestation of Non Income Form SP
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Sample Affidavit of Identity Form Individual SP
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Sample Affidavit of Identity Form Child SP
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Sample W-2 SP
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Sample 2017 Schedule E SP
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Sample 2017 Schedule C SP
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Sample 1040 SP
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Sample US Birth Certificate
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