Forms & Checklists: Benefits

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  • Acknowledgment of Receipt of Notification of COBRA Rights

    Provide this form to an employee if the employee has coverage for himself/herself plus any other family members and coverage is being ended due to termination of employment or reduction in hours. You need to send out additional COBRA notices to those individuals indicated on the form who do not reside with the employee.

  • Cal-COBRA - Notice to Carrier

    Send this notice to the health/disability insurance carrier when any qualified beneficiary becomes subject to Cal-COBRA because of a qualifying event. You must notify the employee’s carrier within 31 days of the event.

  • Cal-COBRA - Notice to Employee

    Send this notice to an employee at least 30 days before a current group benefit plan terminates because of a change in group plans. You must send information about the new group benefit plan, benefits information, premium information, enrollment forms, instructions, etc., necessary to allow the qualified beneficiary (employee) to continue coverage. Send this notice via certified mail and keep a record of the mailing on file.

  • Certificate of Group Health Plan Coverage

    Give this form to employees and any dependents covered by the company’s group health plan as of the COBRA qualifying event. Complete each of the 11 sections before sending and retain a copy with a copy of the COBRA Notice. The employee may need to provide this document to certify any medical advice, diagnosis, care or treatment that was recommended or received for a condition within six months prior to enrollment in a new plan.

  • CHIP-Childrens Health Insurance Program-Model Notice for Employers

    If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums. 

  • CHIPRA Fact Sheet

    The DOL has posted a model Employer children's health insurance program (CHIP) Notice that can be used to satisfy the employer notice requirement under the Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA). CHIPRA added new notice and disclosure obligations for employers that provide group health plans in states that offer Medicaid or state CHIP assistance in the form of premium assistance subsidies.  CHIPRA also created additional HIPAA special enrollment rights that permit eligible employees and their dependents to enroll in an employer's group health plan in two situations: (1) when Medicaid or CHIP coverage is terminated due to loss of eligibility; and (2) upon eligibility for a premium assistance subsidy under Medicaid or CHIP. The Employer CHIP Notice must be provided annually, on an automatic basis and free of charge. It must inform each employee (regardless of enrollment status) of potential opportunities for premium assistance in the state in which the employee resides.

  • COBRA Administration Guide

    Begin using this COBRA administration guide when an employee is hired and refer back to it when a qualifying event occurs. Doing so ensures you use the proper, required forms relating to COBRA (20 or more employees) and Cal-COBRA (2 to 19 employees), as applicable.

    • Download (PDF, 160K)
    • Updated: 8/19/2008
  • COBRA Continuation Coverage Election Notice - California Employees

    Modify this form according to the coverage plans that you offer and send it out with all COBRA notices. The employee is required to fill out and return the form to the plan administrator within 60 days of a qualifying event or the date he/she was notified of COBRA continuation rights.

  • COBRA Continuation Coverage Election Notice - Outside California

    Modify this form according to the coverage plans that you offer and send it out with all COBRA notices. The employee is required to fill out and return the form to the plan administrator within 60 days of a qualifying event or the date he/she was notified of COBRA continuation rights.

  • COBRA Flyer for Employees

    Informational flyer for employees about the COBRA premium reduction extension.

    • Download (PDF, 238K)
    • Updated: 2/5/2010
  • COBRA Flyer for Employees - Spanish

    Informational flyer for employees about the COBRA premium reduction extension.

    • Download (PDF, 211K)
    • Updated: 2/5/2010
  • COBRA Flyer for Employees on Application for Review

    Informational flyer for employees whose request for a COBRA Premium Reduction was denied, includes information about how to request an expedited review.

    • Download (PDF, 293K)
    • Updated: 2/5/2010
  • COBRA Flyer for Employees on Application for Review - Spanish

    Informational flyer for employees whose request for a COBRA Premium Reduction was denied, includes information about how to request an expedited review.

    • Download (PDF, 343K)
    • Updated: 2/5/2010
  • COBRA Flyer for Employers

    Informational flyer for employers about the COBRA premium reduction extension and where to get more information.

    • Download (PDF, 186K)
    • Updated: 2/5/2010
  • COBRA Notice to Plan Administrator

    Use this form to provide notice to the plan administrator within 30 days of an employee's loss of coverage due to termination, reduction in hours, death, or employer bankruptcy.

    • Download (PDF, 115K)
    • Updated: 10/7/2008
  • COBRA Poster

    Poster for employees that includes information on how to protect their health coverage when they lose their jobs.

    • Download (PDF, 175K)
    • Updated: 2/5/2010
  • COBRA Poster - Spanish

    Poster for employees that includes information on how to protect their health coverage when they lose their jobs.

    • Download (PDF, 172K)
    • Updated: 2/5/2010
  • COBRA Premium Reduction Fact Sheet

    Basic Fact Sheet published January 27, 2010 that includes information about the extension and notice requirements.

  • COBRA Premium Reduction Fact Sheet - Spanish

    Basic Fact Sheet published January 27, 2010 that includes information about the extension and notice requirements.

  • COBRA Subsidy Documentation Checklist

    Use this form between September 1, 2008 and December 31,2009 to document information relating to employees receiving the COBRA subsidy. 

  • COBRA Subsidy Extension - Model General Notice - Full Version

    This notice must be sent to all qualified beneficiaries (not just covered employees) who experienced a qualifying event at any time from September 1, 2008 through February 28, 2010, regardless of the type of qualifying event, and who have not yet been provided an election notice. This model notice includes updated information on the premium reduction as well as information required in a COBRA election notice. Note: Individuals who experienced a qualifying event (that was a termination of employment) in December 2009 but who were not eligible for COBRA coverage until January 2010 were likely not provided proper notice. These individuals should get the updated General Notice AND the full 60 days from the date the updated notice is provided to make a COBRA election.qualified beneficiaries, not just covered employees, who experienced a qualifying event at any time from September 1, 2008 through December 31, 2009, regardless of the type of qualifying event, and who either have not yet been provided an election notice or who were provided an election notice on or after February 17, 2009 that did not include the additional information required by ARRA. This full version includes information on the premium reduction as well as information required in the COBRA Continuation Coverage election notice. 

    • Download (DOC, 183K)
    • Updated: 1/21/2010
  • COBRA Subsidy Extension - Model General Notice - Full Version - Spanish

     Plans subject to the Federal COBRA provisions must provide the updated General Notice to all qualified beneficiaries (not just covered employees) who experienced a qualifying event at any time from September 1, 2008 through February 28, 2010, regardless of the type of qualifying event, and who have not yet been provided an election notice. This model notice includes updated information on the premium reduction as well as information required in a COBRA election notice.

    Note: Individuals who experienced a qualifying event (that was a termination of employment) in December 2009 but who were not eligible for COBRA coverage until January 2010 were likely not provided proper notice. These individuals should get the updated General Notice AND the full 60 days from the date the updated notice is provided to make a COBRA election.

    • Download (DOC, 192K)
    • Updated: 2/4/2010
  • COBRA Subsidy Extension - Model Premium Assistance Extension Notice

    Individuals who were "assistance eligible individuals" as of October 31, 2009 (unless they are in a transition period - see below), and individuals who experienced a termination of employment on or after October 31, 2009 and lost health coverage (unless they were already provided a timely, updated General Notice) must be provided notice of the changes made to the premium reduction provisions of ARRA by the 2010 DOD Act by February 17, 2010;

    Individuals who are in a "transition period" must be provided this notice within 60 days of the first day of the transition period. An individual's "transition period" is the period that begins immediately after the end of the maximum number of months (generally nine) of premium reduction available under ARRA prior to its amendment. An individual is in a transition period only if the premium reduction provisions would continue to apply due to the extension from nine to 15 months and they otherwise remain eligible for the premium reduction.

    Note: To some extent, the groups listed above overlap - creating a situation where an individual may be entitled to multiple notices. Providing the Premium Assistance Extension Notice by the earliest date required will satisfy the notice requirement(s).

    • Download (DOC, 112K)
    • Updated: 1/21/2010
  • COBRA Subsidy Extension for Cal-COBRA - Updated Alternative Notice

    Insurance issuers that provide group health insurance coverage must send the Alternative Notice to persons who became eligible for continuation coverage under a State law - this applies to Cal-COBRA. Because continuation coverage requirements vary among States, the DOL is recommending that issuers modify this model notice as necessary to conform it to the applicable State law. Issuers may also find the model Premium Assistance Extension Notice or the updated model General Notice appropriate for use in certain situations.

    Cal-COBRA employers should verify that their carriers have this notice and have updated it accordingly.

    • Download (DOC, 133K)
    • Updated: 1/21/2010
  • General Notice of COBRA Continuation Coverage Rights - California Employees

    Provide this form to an employee or spouse within 90 days of the commencement of coverage or the first date at which the plan administrator is required to advise a qualified beneficiary of the right to elect coverage.

    • Download (PDF, 177K)
    • Updated: 3/23/2009
  • General Notice of COBRA Continuation Coverage Rights - Outside California

    Provide this form to an employee or spouse within 90 days of the commencement of coverage or the first date at which the plan administrator is required to advise a qualified beneficiary of the right to elect coverage. Use this form for employees outside California.

  • HIPP Notice - English

    Send this English version at the same time you send the COBRA Notice, to notify terminating employees of special state programs that provide for the state to pay the COBRA premium under certain circumstances. Be careful not to confuse HIPP, California's Health Insurance Premium Payment Program, with HIPAA.

    • Download (PDF, 30K)
    • Updated: 11/6/2009
  • HIPP Notice - Spanish

    Send this Spanish version at the same time you send the COBRA Notice, to notify Spanish-speaking terminating employees of special state programs that provide for the state to pay the COBRA premium under certain circumstances. Be careful not to confuse HIPP, California's Health Insurance Premium Payment Program, with HIPAA.

    • Download (PDF, 75K)
    • Updated: 11/6/2009
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