Form Instructions
Important Information About Your COBRA Continuation Coverage Rights (Sample 3C)
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.
Instructions for Important Information About Your COBRA Continuation Coverage Rights
In addition to the Election Notice (3A) and
Election Form (3B), the document entitled Important Information About COBRA Continuation Coverage
Rights (3C) must also be completed and provided to qualified beneficiaries. Before
using the sample documents, you should review and revise them to make them consistent
with your plan’s procedures.
- Enter the name of the group health plan.
- Enter the name of the employer/plan administrator and contact information as indicated.