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Click ‘Get Form’ to open it in the editor.
In Part A, select whether your account is Checking or Savings. Fill in the name and address of your financial institution, ensuring all details are accurate.
Attach a voided personal check, savings deposit slip, or a signed bank verification letter as instructed. Ensure your name is pre-printed on the document.
In Part B, read the agreement carefully. Sign and date where indicated to authorize the cancellation of automatic withdrawals.
Complete Part C by entering your case number, name, and telephone number. Ensure that the signature of the case head is included.
Once completed, download or save your form and send it along with any required attachments to the specified address.
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Apply for Marketplace coverage right away You can also apply for a Marketplace plan after your Medicaid or CHIP coverage endsyou have 90 days after your Medicaid or CHIP coverage ends to enroll in a plan that will start at the beginning of the next month after you complete your enrollment.
What are reasons to cancel Medicaid?
Below are the four most common reasons people are losing their Medicaid coverage in 2025: The critical reason for medicaid cancellation: Income Changes. Failure to Renew or Provide Required Documents. Changes in Household Size or Structure. Lack of Response During Redetermination Periods.
How do I contact Medicaid in Alaska?
Medicaid, Food Stamps or Public Assistance questions? Contact: Virtual Contact Center 800-478-7778. Questions about Medicaid claims? Call the Medicaid Recipient Helpline at 800-780-9972.
Does Medicaid stop immediately?
Coverage generally stops at the end of the month in which a person no longer meets the requirements for eligibility.
How do I cancel Medicaid online?
Steps Contact your states health care department. Visit your states marketplace website if you want to cancel online. Select the correct date for your coverage to end. Confirm cancellation of your coverage. Report changed life circumstances if you no longer qualify for Medicaid.
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This dashboard can be used to track the impact of Medicaid expansion on enrollment across the state. It provides an interactive display of public data.
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