Form Instructions
General Notice of Cobra Continuation Coverage Rights
The Consolidated Omnibus Budget Reconciliation Act of 1985 is a federal law. COBRA
allows employees losing employer health plan coverage to continue receiving it through
the employer, but at their own expense, generally for up to 18 months.
As a reminder, HMSA is not the employer/plan administrator (plan administrators
are typically the employer) and therefore does not distribute COBRA notices required
to be furnished by employers/plan administrators. Upon request, however, we can
assist with monthly billings, dues collection, and tracking COBRA coverage periods.
In addition, please note that the form is for use by single-employer group health
plans.
General Notice
Employers/plan administrators must provide covered employees and spouses a general
notice that informs individuals of their COBRA rights and employer notice requirements.
The general notice must normally be provided within 90 days from the date the employee
or spouse first becomes covered under the group health plan, and must contain information
specified in the regulations. This includes the following:
- The name, address and telephone number of someone who can provide additional information
about the plan and continuation coverage;
- A general description of the continuation coverage under the plan, including the
maximum period for which continuation coverage may be available, when and under
what circumstances coverage may be extended, and the plan’s requirements applicable
to the payment of dues; and
- An explanation of the plan’s requirements regarding the responsibility of the employee
or covered dependents to notify the employer/plan administrator of certain events
that may qualify the individual for continuation coverage, and a description of
the plan’s procedures for providing such notice.
Federal law requires employers to provide all employees and their dependents with
a general notice informing them of their COBRA rights. Before using the sample document,
please review and revise it to make it consistent with your plan’s procedures.
When an employee commences employment, provide the COBRA General Notice.
Instructions for General Notice of COBRA Continuing Coverage Rights
- Provide the covered employee and spouse with the General Notice within 90 days of
coverage under group’s health plan.
- Enter plan contact information on page 4.
- Have your employee (and their spouse, if applicable) sign the COBRA General Notice
on page 5 to indicate that they have received the Notice, which advises them of
their rights to continuation coverage.
- File the signed forms in the employee’s personnel file. Forms should be kept for
six years after employment ceases.