Enrollment - Requirements for Enrollment

An Enroll/Cancel/Waive/Change form is required for:

• Enrollment of yourself and/or your dependents.
• The form must be submitted within 31 days of your eligibility date for coverage to begin.
• Changes to your coverage due to the following events:
  • Loss of Eligibility or Medicaid Status.
  • Military Leave.
  • Return to employment following Military Leave or Leave of Absence.
• Termination of coverage.

Coverage is effective the first of the month following or coinciding with the receipt of your form.* Forms must be received within a specific time frame.

The Enroll/Cancel/Waive/Change form can be obtained through your human resources/payroll office and should be sent to:

MCHCP
PO Box 104355
Jefferson City, MO 65110-4355

*Except in cases of life events or military leave.