Form Instructions
COBRA Notification Procedures (Sample 5)
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.
Instructiosn for use of the COBRA Notification Procedures
Qualified beneficiaries must notify plan administrators or employers of a qualifying
event, a second qualifying event, or where the Social Security Administration determines
disability. These procedures must be provided to employees, usually around the time
of hire, so they can provide such notice. Before using the sample document, you
should review and revise it to ensure consistency with your plan’s procedures.
- Enter the name of the plan administrator or indicate that the plan administrator
is the employer.
- Enter "on the form required by the plan administrator" (if a form will
be created). Also, indicate if email is an acceptable form of notification. If it
is, indicate the email address to use, with instructions to keep a hard copy of
the email.
- Enter the address the written notification must be sent to. Include email address,
if applicable.