Model General Notice of COBRA Continuation Coverage RightsElection NoticeNotice To Terminating Employees (for California HIPP Program)
Notice From Employee to Plan Administrator of a Qualifying Event..........1Notice From Employee to Plan Administrator of a Qualifying Event..........2Qualified Beneficiary Election Form for Medical Reimbursement Flexible Spending Account Under The Section 125 Plan..........................................3Unavailability of COBRA Continuation Coverage Notice.............................4Notices for Alternative Coverage.................................................................5
Disability Leaves:...................................................................................................5Family and Medical Leave:....................................................................................5Retirement:............................................................................................................5Waiver of COBRA Coverage in Favor of Alternative Coverage:............................5Revocation of Waiver for COBRA Continuation Coverage:...................................5Guidelines When Using the Waiver of COBRA Continuation Coverage in Favor of Coverage Under the Employer's Alternative Coverage:........................................6
Waiver of COBRA Continuation Coverage in Favor of Coverage Under the Employer's [Alternative Coverage]..............................................................7Revocation of Waiver for COBRA Continuation Coverage...........................8Notice of Changes in Premium or Plan Provisions......................................9Termination of COBRA Continuation Coverage.........................................10Notice of Conversion Rights......................................................................11Disability Determination Notice................................................................12Change of Disability Status Notice............................................................13Qualified Beneficiary Address Change Notice............................................14Notice Regarding Extended California COBRA Continuation....................15Notice of Termination of Cal-COBRA Continuation Coverage Under Self-Funded Group Health Plan........................................................................16
NOTICE FROM EMPLOYEE TOPLAN ADMINISTRATOR OF A QUALIFYING EVENT
DATE: [enter notice date]
TO: Plan Administrator[enter address of Plan Administrator]
FROM: Employee's Name
Street Address
City, State, Zip Code
Social Security Number
(Check Applicable Boxes)
1. As of (insert date) , my spouse (or former spouse) and I became divorced or legally separated. The name and current mailing address of my spouse (or former spouse) is:
______________________________________________________________________________________(Name of Spouse or Former Spouse)
_______________________________________________________________________________________(Number and Street)
NOTICE FROM EMPLOYEE TOPLAN ADMINISTRATOR OF A QUALIFYING EVENT
DATE [enter notice date]
TO: Plan Administrator (Address)
FROM: NAME OF EMPLOYER(Address)
This is to notify you of the occurrence of a qualifying event for purposes of COBRA coverage.
incurred the following qualifying event on ______________________________________.(Name of Person) (Date of Event)
Qualifying Event: ___________________________________________________________________________________ (Termination of employment, reduction in hours, employee's death, employee's Medicare entitlement)
_________________________________________________________________________________ (Date) (Signature of Authorized Representative)
(Title)
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QUALIFIED BENEFICIARY ELECTION FORMFOR MEDICAL REIMBURSEMENT FLEXIBLE SPENDING
ACCOUNT UNDER THE SECTION 125 PLAN
The 1999 proposed regulations contain a rule limiting the application of the COBRA continuation coverage requirements in the case of health FSAs.
Under this rule, if the health FSA satisfies two conditions, the health FSA need not make COBRA continuation coverage available to a qualified beneficiary for any plan year after the plan year in which the qualifying event occurs. The first condition that the health FSA must satisfy for this exception to apply is that the health FSA is not subject to the HIPAA portability provisions because the benefits provided under the health FSA are excepted benefits. The second condition is that, in the plan year in which the qualifying event of a qualified beneficiary occurs, the maximum amount that the health FSA could require to be paid for a full plan year of COBRA continuation coverage equals or exceeds the maximum benefit available under the health FSA for the year. This second condition will be satisfied in most cases.
If a third condition is satisfied, the health FSA need not make COBRA continuation coverage available with respect to a qualified beneficiary at all. This third condition is satisfied if, as of the date of the qualifying event, the maximum benefit available to the qualified beneficiary under the health FSA for the remainder of the plan year is not more than the maximum amount that the plan could require as payment for the remainder of that year to maintain coverage under the health FSA.
In order to continue such participation, qualified beneficiaries are required to contribute with after-tax dollars on the same periodic basis and for the same dollar amount in effect prior to the qualifying event.
Such contributions must be made until the end of the plan year for the qualifying beneficiary to remain covered for the duration of the plan year.
I Do Not Electto Continue
Participation inthe Section 125 Plan
I Do Electto Continue
Participation inthe Section 125 Plan
____________________________________ ( ) ( )(Name of Employee)
_____________________________________ _____________________________________(Date) (Signature of Employee)
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UNAVAILABILITY OF COBRA CONTINUATION COVERAGE NOTICE
[Enter date of notice]
Dear [Enter name of employee, Spouse, and Dependent Children, as appropriate]:
This notice contains important information about your right to continue your health care coverage in the [enter name of group health plan] (the Plan).
After a review of your circumstances, we have determined that you are not qualified to continue health plan coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). This determination is based on the following reason:
[Enter one of the following examples or modify to suit the situation:
You were not a covered individual under the group health plan at the time of the qualifying event.
You did not inform the Plan Administrator of the [divorce, legal separation, dependent’s loss of eligibility] within 60 days of this qualifying event.
You were terminated from employment for gross misconduct, which is not a qualifying event under COBRA.]
If you have additional information about these circumstances, please provide it to the Plan Administrator [enter name, address and phone of Plan Administrator] as soon as possible so that we can determine if there is any basis for reconsidering your disqualification for COBRA continuation coverage.
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NOTICES FOR ALTERNATIVE COVERAGE
The following sample notices are intended to explain the coordination of three types of alternative coverage with an employee's COBRA rights: disability leave, family and medical leave, and retirement. Of course, the information in these forms could change depending on how employers choose to coordinate the alternative coverage with COBRA coverage.
DISABILITY LEAVES: A disability leave (except medical leave under FMLA) is a qualifying event because it results in a reduction in hours of employment. This means an employer can choose to begin the COBRA coverage period at the same time as the employee's leave, provided the health coverage under the disability leave policy is identical to COBRA coverage. In this case, an initial notice should be sent by the Plan Administrator at the commencement of the employee's disability leave. On or before the expiration of the leave, a second notice should be sent to the employee. Samples of both notices are included in this section.
FAMILY AND MEDICAL LEAVE: Under the Family and Medical Leave Act, employers must provide up to 12 weeks of unpaid leave and medical benefits, due to certain events. However, while COBRA may provide that leaves of absence are qualifying events depending on the employer’s own policies, FMLA leave is not considered a qualifying event. Therefore, any health coverage provided during the leave period is not COBRA coverage and will not be credited against COBRA.
The qualifying event under COBRA occurs if; 1) an employee (or the spouse or a dependent child of the employee) is covered on the day before the first day of FMLA leave (or becomes covered during the FMLA leave) under a group health plan of the employee’s employer, 2) the employee does not return to employment with the employer at the end of the FMLA leave, and 3) the employee (or the spouse or a dependent child of the employee) would, in the absence of COBRA continuation coverage, lose coverage under the group health plan before the end of what would be the maximum coverage period. Once a qualifying event occurs, employers must follow COBRA’s notice requirements. Because of the variables involved in administering COBRA coverage and FMLA leave, the employer should always seek legal counsel.
RETIREMENT: A retirement is considered a termination of employment for COBRA purposes, and therefore, an employer can use the COBRA notice designed for termination of employment for retirees. However, when the employer provides a retiree health plan and the plan meets COBRA's requirements (i.e., the retiree coverage is identical to COBRA coverage), the employer can choose to treat the retirement as the qualifying event. This means the COBRA coverage and the retiree coverage will run at the same time. In this case, the employer can adapt the format of the election notice for retirees.
WAIVER OF COBRA COVERAGE IN FAVOR OF ALTERNATIVE COVERAGE: 5
When an employer provides alternative coverage, such as a severance or retirement package, that is not identical to COBRA coverage, it may decide to offer the ex-employee the choice between the alternative coverage and COBRA coverage. If that is the case, such a choice should clearly indicate that the ex-employee is waiving his or her COBRA rights. A sample notice is included.
REVOCATION OF WAIVER FOR COBRA CONTINUATION COVERAGE: Employers should note that an ex-employee can revoke his or her waiver as long as it is done before the end of the 60-day election period. A sample revocation notice is also provided
GUIDELINES WHEN USING THE WAIVER OF COBRA CONTINUATION COVERAGE IN FAVOR OF COVERAGE UNDER THE EMPLOYER'S ALTERNATIVE COVERAGE : When an employer provides alternative coverage such as severance, retirement or leave of absence, these coverages can be offered as separate from COBRA coverage. If the employer decides to offer an employee the choice between the alternative coverage and COBRA, such a choice should be clearly documented. The employee waiving his or her COBRA rights needs to be in writing. The following form is to be used to document such a waiver. Employers should note that an employee can revoke his or her waiver as long as it is done before the end of the 60-day election period. An example of a revocation form is also provided, following the waiver form.
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WAIVER OF COBRA CONTINUATION COVERAGE IN FAVOR OF COVERAGE UNDER THE EMPLOYER'S [ALTERNATIVE
COVERAGE]
Waiver Agreement
I, , have received explanations and understand the rights that apply under COBRA coverage and the Employer's [type of alternative coverage]. I hereby elect to be covered under the Employer's [alternative coverage] and waive continuation coverage under COBRA. I understand that by making this election, group health coverage will terminate on or, if earlier, the date of termination of employment or failure to pay the premium on time. I also understand that once this alternative coverage ends, I will not have any continuation coverage rights under COBRA. However, if my death or Medicare entitlement, a divorce or legal separation, or cessation of dependent status occurs while covered under the alternative coverage, my spouse and/or dependent children, if any, may have additional COBRA rights.
Print Name Signature Relationship Date1.2.3.4.
Received by Plan Administrator:__________________________________Date:_____________
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REVOCATION OF WAIVER FORCOBRA CONTINUATION COVERAGE
This notice constitutes my decision to revoke my waiver of my rights to COBRA continuation coverage, which was made on . I understand that by revoking the waiver, my COBRA coverage period will begin on the date of this revocation, and not the date of my original COBRA qualifying event. Accordingly, any medical expenses incurred between the date of the qualifying event and the date of this revocation will not be covered by the Plan.
I also understand my rights and responsibilities provided under COBRA coverage, as specified in my original COBRA notice and election form.
Print Name Signature Relationship Date1.2.3.4.
Received by Plan Administrator:__________________________________Date:_____________
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NOTICE OF CHANGES IN PREMIUM OR PLAN PROVISIONS
[Enter date of notice]
Dear [Enter name of employee, Spouse, and Dependent Children, as appropriate]:
This notice contains important information about your right to continue your health care coverage in the [enter name of group health plan] (the Plan).
For each plan year, the Plan determines the monthly premium for COBRA continuation coverage. For the upcoming plan year, beginning [enter date plan year begins] through [enter date plan year ends], the cost for your COBRA continuation coverage will be:
Single: $[enter single rate applicable to qualified beneficiary]Two Party: $[enter two party rate applicable to qualified beneficiary]Family: $[enter family rate applicable to qualified beneficiary][Include rates for all lines of coverage the qualified beneficiary is enrolled in]
The new rate will apply to your premium payment for continuation coverage due on [enter due date for new premium rate]. Please remit the new premium rate beginning on that due date.
[If the Plan provides an annual open enrollment period for active employees, include the following: Information about the annual open enrollment and the cost of any coverage options you may be eligible to select [is included or will be sent to you].]
[If any plan changes affect the qualified beneficiary’s coverage, include the following: Effective [enter date of changes], there will be changes to the Plan provisions. Details of the plan changes are included with this notice.]
9
TERMINATION OF COBRA CONTINUATION COVERAGE
[Enter date of notice]
Dear [Enter name of employee, Spouse, and Dependent Children, as appropriate]:
This notice contains important information about your right to continue your health care coverage in the [enter name of group health plan] (the Plan).
We have determined that your COBRA continuation coverage under the Plan [terminated or will terminate] on [enter COBRA termination date]. Your continuation coverage terminated before the maximum period because [enter one of the following reasons or modify to suit the situation:You did not pay your required premium for continuation coverage on a timely basis.You became covered under another group health plan on [date].You became entitled to Medicare on [date].The employer has terminated all group health plan coverage effective [date].Enter any other reason for loss of eligibility as defined by the group health plan.]You may have rights to additional coverage. [If individual conversion is available, state that the “Notice of Conversion Rights” found on the next page of this COBRA manual is enclosed, and include with this notice.]
If you have additional information about these circumstances, please provide it to the Plan Administrator [enter name, address and phone of Plan Administrator] as soon as possible so that we can determine if there is any basis for reconsidering the termination of your COBRA continuation coverage.
10
NOTICE OF CONVERSION RIGHTS
DATE [enter date of notice]
TO: [Qualified Beneficiary's Name][Address]
FROM: PLAN ADMINISTRATOR[Address]
RE: NOTICE OF CONVERSION RIGHTS
Subject to your continued eligibility and payment of premium, your COBRA health coverage will terminate on [enter date COBRA scheduled to end]. You have the right to convert your health coverage to an individual health policy as provided by the plan. If you wish to exercise this privilege, you must notify us before your COBRA coverage expires.
Please examine your options carefully before declining this coverage. You should be aware that companies selling individual health insurance typically require a review of your medical history that could result in higher premium or you could be denied coverage entirely.
If you have any questions, please do not hesitate to call.
11
DISABILITY DETERMINATION NOTICE
[Enter name and address of Plan Administrator]
I have received the attached determination from the Social Security Administration that I was disabled according to Social Security guidelines at the time of my qualifying event, or became disabled within the first 60 days of my COBRA coverage. I am applying for an extension to my COBRA continuation coverage under the regulations providing for the extension for a disabled qualified beneficiary.
A copy of the determination from the Social Security Administration, dated ________________, is attached and I am providing notification to the Plan Administrator within 60 days of the latest of either the determination, the date the qualifying event occurred, the date which I loss coverage under COBRA, or the date I was informed of my obligation to provide the disability notice. I understand that if the disability extension to my COBRA continuation coverage is approved, my premiums for the 19th through 29th month of coverage will increase to 150% of the applicable group rate in accordance with the regulations.
If the Social Security Administration later determines that I am no longer disabled under the Social Security guidelines, I understand and acknowledge that I am required to notify the Plan Administrator within 30 days of the new determination that I am no longer disabled. I understand that my disability extension for COBRA continuation coverage will terminate if I am determined to be no longer disabled.
Print Name ____________________________________
Signature ____________________________________
Date: ____________________________________
12
CHANGE OF DISABILITY STATUS NOTICE
[Enter name and address of Plan Administrator]
I received the attached determination from the Social Security Administration that I am no longer disabled according to Social Security guidelines. A copy of the determination from the Social Security Administration, dated ________________, is attached and I am providing notification to the Plan Administrator within 30 days of the determination.
I understand that my disability extension for COBRA continuation coverage will terminate if I am determined to be no longer disabled.
Print Name ____________________________________
Signature ____________________________________
Date: ____________________________________
13
QUALIFIED BENEFICIARY ADDRESS CHANGE NOTICE
[Enter Name and Address of Plan Administrator]
As of ______________________________ , my mailing address for receiving notices about my
(enter date)continuation coverage will change to:
Name: ___________________________________________
Number and Street: ___________________________________________
NOTICE REGARDING EXTENDED CALIFORNIA COBRA CONTINUATION
Extension of Medical Continuation Coverage Following Federal COBRA Coverage Under California Chapter 749, Statutes of 2002 (AB 1401)
Legislation enacted in California may allow you to expand your continuation coverage up to a total of 36 months if you are eligible for less than 36 months of federal COBRA continuation coverage. You may only qualify for this additional continuation coverage if:
1. Your COBRA qualifying event occurred on or after January 1, 2003;2. You are eligible for less than 36 months of COBRA continuation
coverage under federal law; and3. You are covered under one of the following medical insurance or HMO
plans:o [Insert list of fully-insured medical plans/HMOs offered by the
employer]o …
A health insurer providing coverage under an employer-sponsored group health plan must offer this extended coverage, known as “CalCOBRA”, to participants who meet the three requirements described above. The health plan offering this extension will notify you shortly before your federal COBRA coverage expires, and will provide details on enrollment and how to continue making your premium payments.
CalCOBRA coverage does not apply to dental-only, vision-only, accident-only, specified disease, hospital indemnity, CHAMPUS supplement, long-term care, or Medicare supplement insurance policies. Additionally, CalCOBRA does NOT apply to any self-funded medical plan sponsored by the employer, including [insert name of self-funded medical plans of the employer]. This law was effective on September 1, 2003, and applies only to individuals who BEGAN their COBRA coverage on or after January 1, 2003.
Under CalCOBRA, the health insurer is required to offer continuation coverage at a rate that is not more than 110% of the applicable rate charged for an active employee or, in the case of dependent coverage, not more than 110% of the applicable rate charged to a similarly situated individual under the group benefit plan. Different rates and coverage durations apply to persons who have been determined, for Social Security purposes, to be totally disabled. In the case of a qualified beneficiary who is determined to be disabled, the qualified beneficiary would be required to pay the insurer not more than 150% of the group rate after the first 18 months of continuation coverage provided.
15
If you have further questions about this extended continuation coverage, please contact Member Services for your health plan at the number shown on your medical plan identification card.
This preliminary notification of these new California provisions does not imply that you will be entitled to the expanded continuation benefits at the time your COBRA coverage terminates. Any offer of expanded continuation coverage, and determination of your eligibility for such expanded coverage, will be made by the insurance company or health plan you are covered by at that time.
16
NOTICE OF TERMINATION OF CAL-COBRA CONTINUATION COVERAGE UNDER SELF-FUNDED GROUP HEALTH PLAN
[Enter date of notice]
Dear [Enter name of employee, Spouse, and Dependent Children, as appropriate]:
This notice contains important information about your right to continue your health care coverage in the [enter name of group health plan] (the Plan).
Subject to your continued eligibility and payment of premium, your Cal-COBRA health coverage will terminate on [enter date Cal-COBRA scheduled to end]. Your continuation coverage will terminate before the expiration of the maximum period of coverage because [enter name of employer] is changing from a fully insured group health plan to a self-funded group health plan. You have rights under state and federal law to convert your current health coverage to an individual health policy.
Generally, individuals are eligible for conversion coverage if they have had health insurance for the previous 18 months, were most recently in an employer-sponsored group health plan, have used up all their federal COBRA or Cal-COBRA coverage, do not have other health insurance and did not most recently lose health insurance due to failure to pay premiums or attempts to deceive the previous health insurer. The health insurance carrier must receive a qualifying individual’s application and first premium payment within 63 days after the group health insurance coverage ends.
Additionally, you and each of your dependents under the Plan are entitled to receive a Certificate of Creditable Coverage (also known as a “HIPAA Certificate”) as evidence of your coverage under the Plan. The HIPAA Certificate must be furnished by [enter name of Plan’s outgoing insurance carrier]. Contact information for [enter name of Plan’s outgoing insurance carrier] is as follows:
[enter carrier contact information]
You are urged to contact [enter name of Plan’s outgoing insurance carrier] as soon as possible, in order to preserve all potential health insurance options available to you when your coverage under the Plan terminates.
If you have any questions, please do not hesitate to call.
17
Name of Qualified Beneficiary: [enter name of qualified beneficiary] ID Number: [enter identifier as appropriate]
Date of Qualifying Event: [enter date] Loss of Coverage Date: [if different from qualifying event date]Determination of dates affecting the qualified beneficiaryQualifying Event
[enter type of qualifying event]
Timetable Timing Requirement Date Applicable To This Qualified Beneficiary
Remarks
Notice to Plan Administrator of Qualifying Event
Employer: within 30 days Employee: within 60 days
[enter due date for notice]
Provision of Election Notice or Unavailability of Continuation
Plan Administrator must provide to qualified beneficiaries within 14 days after receiving notice of a qualifying event
[enter due date for notice]
Election Period
Within 60 days from date of election notice
Election period ends:[enter date election period ends]Election date:[enter election date, if any]
Initial Premium Payment
Within 45 days after date of election
[enter due date for initial premium]
Monthly Premium Payment
Within 30 days of the monthly due date (or longer grace period if employer has more time to pay premium to health plan)
Due date: [enter day]of each monthGrace period: [number] days
Open Enrollment or Premium Change
When provided to active participants of plan. Changes in plan or premium within 60 days
[enter dates for notices]
Maximum Coverage Period
18 months – Termination or Reduction in Hours36 months – All other qualifying events
[enter date based on qualifying event or loss of coverage, as appropriate]
Second Qualifying Event During Coverage Period
Maximum coverage extended to 36 months from first qualifying event;Not applicable to 36-month qualifying events
[Enter date of second qualifying event if one occurs, and revise maximum coverage period date to reflect extension]
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Notification of Qualified Beneficiary’s Disability
Must notify within 60 days of determination (extends coverage to 29 months); Not applicable to 36-month qualifying events
[If applicable, enter date employee provided notice and revise maximum coverage period date to reflect extension]
Notification QB No Longer Disabled
Qualified beneficiary must notify within 30 days
[If applicable, enter date employee provided notice and provide termination notice]
Early Termination of Continuation Coverage
Late premium payment Coverage under another group plan Medicare entitlement Employer terminates all group plans
[If applicable, enter date of early COBRA termination]
Provision of Conversion Notice
Within 180 days before end of continuation coverage
[Enter date, determined from end of maximum coverage period]
Provision of Certificate of Creditable Coverage
Individual becomes entitled to COBRA coverage
[enter due date for notice]
Continuation coverage terminates
[enter due date for notice]
Upon request within 24 months of loss of coverage
[enter date sent if requested]
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Name of Qualified Beneficiary: [enter name of qualified beneficiary] ID Number: [enter identifier as appropriate]
Date of Qualifying Event: [enter date] Loss of Coverage Date: [if different from qualifying event date]
Record of notices provided by Employer/Plan AdministratorType of Notice Timing Requirement Date Notice
SentRemarks
General Notice of COBRA Rights
No later than 90 days after coverage under the plan begins
[enter date sent]
Qualifying Event – Termination of Employment/Reduction in Hours/Death of Employee/Medicare Entitlement/Bankruptcy
Employer must notify plan administrator no later than 30 days after the Qualifying Event (or if COBRA begins on loss of coverage, 30 days after loss of coverage)
[enter date sent]
Election Notice No later than 14 days after receipt of qualifying event notice
[enter date sent]
Unavailability of COBRA Continuation
No later than 14 days after receipt of qualifying event notice
[If applicable, enter date sent]
Termination of Continuation Coverage (effective earlier than maximum period applicable)
As soon as practicable following determination that continuation coverage shall terminate before maximum coverage period
[If applicable, enter date sent]
Open Enrollment or Changes in Plan Provisions/Premiums (each plan year in continuation)
When provided to active participants of plan. Changes in plan or premium within 60 days
Year Date Sent1: [enter date sent]2: [enter date sent]3: [enter date sent]
Conversion Notice Within 180 days before end of continuation coverage
[enter date sent]
Certificate of Creditable Coverage
Upon any of the following occurrences:1. When individual
becomes entitled to COBRA
2. When COBRA coverage terminates
3. Upon request of individual within 24 months of loss of coverage.
[enter date sent]
CALIFORNIA ONLY (see Interaction With California Continuation Coverage Laws)
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Department of Health Services Notice to Terminating Employees
Provide HIPP notice to terminating employee with COBRA Election Notice
[enter date sent]
Expanded California COBRA Continuation(Requirement for fully-insured plans only)
Prior to end of COBRA coverage to Qualified Beneficiaries with less than 36 months of federal COBRA continuation coverage
