Model Cobra Continuation Coverage Election Notice Form

This fillable "Model Cobra Continuation Coverage Election Notice Form" is a document issued by the U.S. Department of Labor specifically for United States residents.

Download the PDF by clicking the link below and complete it directly in your browser or through the Adobe Desktop application.

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Model COBRA Continuation Coverage Election Notice
(For use by single-employer group health plans)
[Enter date of notice]
Dear: [Identify the qualified beneficiary(ies), by name or status]
This notice contains important information about your right to continue your health care
coverage in the [enter name of group health plan] (the Plan), as well as other health
coverage alternatives that may be available to you through the Health Insurance
Marketplace. Please read the information contained in this notice very carefully.
To elect COBRA continuation coverage, follow the instructions on the next page to complete the
enclosed Election Form and submit it to us.
If you do not elect COBRA continuation coverage, your coverage under the Plan will end on
[enter date] due to [check appropriate box]:
 End of employment
 Reduction in hours of employment
 Death of employee
 Divorce or legal separation
 Entitlement to Medicare
 Loss of dependent child status
Each person (“qualified beneficiary”) in the category(ies) checked below is entitled to elect
COBRA continuation coverage, which will continue group health care coverage under the Plan
for up to ___ months [enter 18 or 36, as appropriate and check appropriate box or boxes;
names may be added]:
 Employee or former employee
 Spouse or former spouse
 Dependent child(ren) covered under the Plan on the day before the event that caused
the loss of coverage
 Child who is losing coverage under the Plan because he or she is no
longer a dependent under the Plan
If elected, COBRA continuation coverage will begin on [enter date] and can last until [enter
date].
[Add, if appropriate: You may elect any of the following options for COBRA continuation
coverage: [list available coverage options].
COBRA continuation coverage will cost: [enter amount each qualified beneficiary will be
required to pay for each option per month of coverage and any other permitted coverage
periods.] You do not have to send any payment with the Election Form. Important additional
information about payment for COBRA continuation coverage is included in the pages following
the Election Form.
Model COBRA Continuation Coverage Election Notice
(For use by single-employer group health plans)
[Enter date of notice]
Dear: [Identify the qualified beneficiary(ies), by name or status]
This notice contains important information about your right to continue your health care
coverage in the [enter name of group health plan] (the Plan), as well as other health
coverage alternatives that may be available to you through the Health Insurance
Marketplace. Please read the information contained in this notice very carefully.
To elect COBRA continuation coverage, follow the instructions on the next page to complete the
enclosed Election Form and submit it to us.
If you do not elect COBRA continuation coverage, your coverage under the Plan will end on
[enter date] due to [check appropriate box]:
 End of employment
 Reduction in hours of employment
 Death of employee
 Divorce or legal separation
 Entitlement to Medicare
 Loss of dependent child status
Each person (“qualified beneficiary”) in the category(ies) checked below is entitled to elect
COBRA continuation coverage, which will continue group health care coverage under the Plan
for up to ___ months [enter 18 or 36, as appropriate and check appropriate box or boxes;
names may be added]:
 Employee or former employee
 Spouse or former spouse
 Dependent child(ren) covered under the Plan on the day before the event that caused
the loss of coverage
 Child who is losing coverage under the Plan because he or she is no
longer a dependent under the Plan
If elected, COBRA continuation coverage will begin on [enter date] and can last until [enter
date].
[Add, if appropriate: You may elect any of the following options for COBRA continuation
coverage: [list available coverage options].
COBRA continuation coverage will cost: [enter amount each qualified beneficiary will be
required to pay for each option per month of coverage and any other permitted coverage
periods.] You do not have to send any payment with the Election Form. Important additional
information about payment for COBRA continuation coverage is included in the pages following
the Election Form.
There may be other coverage options for you and your family. When key parts of the health care
law take effect, you’ll be able to buy coverage through the Health Insurance Marketplace. In the
Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly
premiums right away, and you can see what your premium, deductibles, and out-of-pocket costs
will be before you make a decision to enroll. Being eligible for COBRA does not limit your
eligibility for coverage for a tax credit through the Marketplace. Additionally, you may qualify
for a special enrollment opportunity for another group health plan for which you are eligible
(such as a spouse’s plan), even if the plan generally does not accept late enrollees, if you request
enrollment within 30 days.
If you have any questions about your rights to COBRA continuation coverage, you should
contact [enter name of party responsible for COBRA administration for the Plan, with telephone
number and address].
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COBRA Continuation Coverage Election Form
:
Instructions
To elect COBRA continuation coverage, complete this Election Form and return it to
us. Under federal law, you must have 60 days after the date of this notice to decide whether you want
to elect COBRA continuation coverage under the Plan.
Send completed Election Form to: [Enter Name and Address]
This Election Form must be completed and returned by mail [or describe other means of submission and
due date]. If mailed, it must be post-marked no later than [enter date].
If you do not submit a completed Election Form by the due date shown above, you will lose your right
to elect COBRA continuation coverage. If you reject COBRA continuation coverage before the due
date, you may change your mind as long as you furnish a completed Election Form before the due date.
However, if you change your mind after first rejecting COBRA continuation coverage, your COBRA
continuation coverage will begin on the date you furnish the completed Election Form.
Read the important information about your rights included in the pages after the Election Form.
I (We) elect COBRA continuation coverage in the [enter name of plan] (the Plan) as indicated
below:
Name
Date of Birth
Relationship to Employee
SSN (or other identifier)
a. _________________________________________________________________________
[Add if appropriate: Coverage option elected: _______________________________]
b. _________________________________________________________________________
[Add if appropriate: Coverage option elected: _______________________________]
c. _________________________________________________________________________
[Add if appropriate: Coverage option elected: _______________________________]
_____________________________________
_____________________________
Signature
Date
______________________________________
_____________________________
Print Name
Relationship to individual(s) listed above
______________________________________
______________________________________
______________________________________
______________________________
Print Address
Telephone number
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Important Information
About Your COBRA Continuation Coverage Rights
What is continuation coverage?
Federal law requires that most group health plans (including this Plan) give employees and their
families the opportunity to continue their health care coverage when there is a “qualifying event”
that would result in a loss of coverage under an employer’s plan. Depending on the type of
qualifying event, “qualified beneficiaries” can include the employee (or retired employee)
covered under the group health plan, the covered employee’s spouse, and the dependent children
of the covered employee.
Continuation coverage is the same coverage that the Plan gives to other participants or
beneficiaries under the Plan who are not receiving continuation coverage. Each qualified
beneficiary who elects continuation coverage will have the same rights under the Plan as other
participants or beneficiaries covered under the Plan, including [add if applicable: open
enrollment and] special enrollment rights.
How long will continuation coverage last?
In the case of a loss of coverage due to end of employment or reduction in hours of employment,
coverage generally may be continued for up to a total of 18 months. In the case of losses of
coverage due to an employee’s death, divorce or legal separation, the employee’s becoming
entitled to Medicare benefits or a dependent child ceasing to be a dependent under the terms of
the plan, coverage may be continued for up to a total of 36 months. When the qualifying event is
the end of employment or reduction of the employee's hours of employment, and the employee
became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA
continuation coverage for qualified beneficiaries other than the employee lasts until 36 months
after the date of Medicare entitlement. This notice shows the maximum period of continuation
coverage available to the qualified beneficiaries.
Continuation coverage will be terminated before the end of the maximum period if:
 any required premium is not paid in full on time,
 a qualified beneficiary becomes covered, after electing continuation coverage, under
another group health plan that does not impose any pre-existing condition exclusion for a
pre-existing condition of the qualified beneficiary (note: there are limitations on plans’
imposing a preexisting condition exclusion and such exclusions will become prohibited
beginning in 2014 under the Affordable Care Act),
 a qualified beneficiary becomes entitled to Medicare benefits (under Part A, Part B, or
both) after electing continuation coverage, or
 the employer ceases to provide any group health plan for its employees.
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Continuation coverage may also be terminated for any reason the Plan would terminate coverage
of a participant or beneficiary not receiving continuation coverage (such as fraud).
[If the maximum period shown on page 1 of this notice is less than 36 months, add the following
three paragraphs:]
How can you extend the length of COBRA continuation coverage?
If you elect continuation coverage, an extension of the maximum period of coverage may be
available if a qualified beneficiary is disabled or a second qualifying event occurs. You must
notify [enter name of party responsible for COBRA administration] of a disability or a second
qualifying event in order to extend the period of continuation coverage. Failure to provide notice
of a disability or second qualifying event may affect the right to extend the period of
continuation coverage.
Disability
An 11-month extension of coverage may be available if any of the qualified beneficiaries is
determined by the Social Security Administration (SSA) to be disabled. The disability has to
have started at some time before the 60th day of COBRA continuation coverage and must last at
least until the end of the 18-month period of continuation coverage. [Describe Plan provisions
for requiring notice of disability determination, including time frames and procedures.] Each
qualified beneficiary who has elected continuation coverage will be entitled to the 11-month
disability extension if one of them qualifies. If the qualified beneficiary is determined by SSA to
no longer be disabled, you must notify the Plan of that fact within 30 days after SSA’s
determination.
Second Qualifying Event
An 18-month extension of coverage will be available to spouses and dependent children who
elect continuation coverage if a second qualifying event occurs during the first 18 months of
continuation coverage. The maximum amount of continuation coverage available when a second
qualifying event occurs is 36 months. Such second qualifying events may include the death of a
covered employee, divorce or separation from the covered employee, the covered employee’s
becoming entitled to Medicare benefits (under Part A, Part B, or both), or a dependent child’s
ceasing to be eligible for coverage as a dependent under the Plan. These events can be a second
qualifying event only if they would have caused the qualified beneficiary to lose coverage under
the Plan if the first qualifying event had not occurred. You must notify the Plan within 60 days
after a second qualifying event occurs if you want to extend your continuation coverage.
How can you elect COBRA continuation coverage?
To elect continuation coverage, you must complete the Election Form and furnish it according to
the directions on the form. Each qualified beneficiary has a separate right to elect continuation
coverage. For example, the employee’s spouse may elect continuation coverage even if the
employee does not. Continuation coverage may be elected for only one, several, or for all
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