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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). Please read the information contained in this notice very
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
||Spouse or former
covered under the Plan on the day before the event that caused
||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.
If you have any questions about this notice or your rights to COBRA
continuation coverage, you should contact [enter name of party
responsible for COBRA administration for the Plan, with telephone number
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)
if appropriate: Coverage option elected:]
if appropriate: Coverage option elected:]
if appropriate: Coverage option elected:]
Relationship to individual(s) listed above
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 only 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
Continuation coverage will be terminated before the end of the maximum
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.
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 dependent children who are qualified beneficiaries. A
parent may elect to continue coverage on behalf of any dependent children.
The employee or the employee's spouse can elect continuation coverage on
behalf of all of the qualified beneficiaries.
In considering whether to elect continuation coverage, you should take
into account that a failure to continue your group health coverage will
affect your future rights under federal law. First, you can lose the right
to avoid having pre-existing condition exclusions applied to you by other
group health plans if you have more than a 63-day gap in health coverage,
and election of continuation coverage may help you not have such a gap.
Second, you will lose the guaranteed right to purchase individual health
insurance policies that do not impose such pre-existing condition
exclusions if you do not get continuation coverage for the maximum time
available to you. Finally, you should take into account that you have
special enrollment rights under federal law. You have the right to request
special enrollment in another group health plan for which you are
otherwise eligible (such as a plan sponsored by your spouse’s employer)
within 30 days after your group health coverage ends because of the
qualifying event listed above. You will also have the same special
enrollment right at the end of continuation coverage if you get
continuation coverage for the maximum time available to you.
How much does COBRA continuation coverage cost?
Generally, each qualified beneficiary may be required to pay the entire
cost of continuation coverage. The amount a qualified beneficiary may be
required to pay may not exceed 102 percent (or, in the case of an
extension of continuation coverage due to a disability, 150 percent) of
the cost to the group health plan (including both employer and employee
contributions) for coverage of a similarly situated plan participant or
beneficiary who is not receiving continuation coverage. The required
payment for each continuation coverage period for each option is described
in this notice.
[If employees might be eligible for trade adjustment assistance, the
following information may be added:] The Trade Act of 2002 created a new
tax credit for certain individuals who become eligible for trade
adjustment assistance and for certain retired employees who are receiving
pension payments from the Pension Benefit Guaranty Corporation (PBGC)
(eligible individuals). Under the new tax provisions, eligible individuals
can either take a tax credit or get advance payment of 65% of premiums
paid for qualified health insurance, including continuation coverage. If
you have questions about these new tax provisions, you may call the Health
Coverage Tax Credit Customer Contact Center toll-free at 1-866-628-4282.
TTD/TTY callers may call toll-free at 1-866-626-4282. More information
about the Trade Act is also available at
When and how must payment for COBRA continuation coverage be made?
First payment for continuation coverage
If you elect continuation coverage, you do not have to send any payment
with the Election Form. However, you must make your first payment for
continuation coverage not later than 45 days after the date of your
election. (This is the date the Election Notice is post-marked, if
mailed.) If you do not make your first payment for continuation coverage
in full not later than 45 days after the date of your election, you will
lose all continuation coverage rights under the Plan. You are responsible
for making sure that the amount of your first payment is correct. You may
contact [enter appropriate contact information, e.g., the Plan
Administrator or other party responsible for COBRA administration under
the Plan] to confirm the correct amount of your first payment.
Periodic payments for continuation coverage
After you make your first payment for continuation coverage, you will be
required to make periodic payments for each subsequent coverage period.
The amount due for each coverage period for each qualified beneficiary is
shown in this notice. The periodic payments can be made on a monthly
basis. Under the Plan, each of these periodic payments for continuation
coverage is due on the [enter due day for each monthly payment] for that
coverage period. [If Plan offers other payment schedules, enter with
appropriate dates: You may instead make payments for continuation coverage
for the following coverage periods, due on the following dates:]. If you
make a periodic payment on or before the first day of the coverage period
to which it applies, your coverage under the Plan will continue for that
coverage period without any break. The Plan [select one: will or will not]
send periodic notices of payments due for these coverage periods.
Grace periods for periodic payments
Although periodic payments are due on the dates shown above, you will be
given a grace period of 30 days after the first day of the coverage period
[or enter longer period permitted by Plan] to make each periodic payment.
Your continuation coverage will be provided for each coverage period as
long as payment for that coverage period is made before the end of the
grace period for that payment. [If Plan suspends coverage during grace
period for nonpayment, enter and modify as necessary: However, if you pay
a periodic payment later than the first day of the coverage period to
which it applies, but before the end of the grace period for the coverage
period, your coverage under the Plan will be suspended as of the first day
of the coverage period and then retroactively reinstated (going back to
the first day of the coverage period) when the periodic payment is
received. This means that any claim you submit for benefits while your
coverage is suspended may be denied and may have to be resubmitted once
your coverage is reinstated.]
If you fail to make a periodic payment before the end of the grace period
for that coverage period, you will lose all rights to continuation
coverage under the Plan.
Your first payment and all periodic payments for continuation coverage
should be sent to:
[enter appropriate payment address]
For more information
This notice does not fully describe continuation coverage or other rights
under the Plan. More information about continuation coverage and your
rights under the Plan is available in your summary plan description or
from the Plan Administrator.
If you have any questions concerning the information in this notice, your
rights to coverage, or if you want a copy of your summary plan
description, you should contact [enter name of party responsible for COBRA
administration for the Plan, with telephone number and address].
For more information about your rights under ERISA, including COBRA, the
Health Insurance Portability and Accountability Act (HIPAA), and other
laws affecting group health plans, contact the U.S. Department of Labor’s
Employee Benefits Security Administration (EBSA) in your area or visit the
EBSA website at www.dol.gov/ebsa . (Addresses and phone numbers of Regional
and District EBSA Offices are available through EBSA’s website.)
Keep Your Plan Informed of Address Changes
In order to protect your and your family’s rights, you should keep the
Plan Administrator informed of any changes in your address and the
addresses of family members. You should also keep a copy, for your
records, of any notices you send to the Plan Administrator.
One Stamford Landing, Suite 101,
Stamford, CT 06902
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