COBRA Continuation of Coverage Request Template
Plan administrators, upon receiving notice of a qualifying event, must provide an election notice – COBRA Continuation of Coverage Request Template – to the qualified beneficiaries of their right to elect COBRA coverage. COM106-1 CONTINUATION OF COVERAGE (COBRA NOTICE/ELECTION FORM) must be provided in person or by first class mail within 14 days after the plan administrator receives notice that a qualifying event has occurred.
There are two special exceptions to the notice requirements for multi-employer plans. First, the period for providing notices may be extended beyond the 14- and 30-day requirements if allowed by plan rules. Second, if the plan rules allow, employers may be relieved of the obligation to notify plan administrators when employees terminate or reduce their work hours. Plan administrators would then be responsible for determining whether these qualifying events have occurred.
COBRA continuation coverage can be terminated for the following reasons:
- On the date that the employer ends a group health plan to all employees.
- At the time that the qualifying beneficiary becomes qualified to participate in another group plan offered from new employment.
- If the beneficiary fails to make timely payments to the provider for the continuation coverage.
- The date on which a qualified beneficiary is entitled to benefits under Medicare.
COBRA Continuation of Coverage Request Template Details
Format: Microsoft Word 2013 (.docx)
Manual: Human Resources
Procedure: Consolidated Budget Reconciliation Procedure COBRA COM106
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