Form Instructions
Notice of Unavailability (Sample 6)
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.
Before using this sample form, you should review and revise it to ensure consistency
with your plan’s procedures.
The Department of Labor mandate:
If the employer/plan administrator determines that an individual is not eligible
for COBRA continuation coverage, or extended COBRA continuation coverage after the
occurrence of a second qualifying event, the employer/plan administrator must notify
the affected individual of this within 14 days after receiving the election notice.
Instructions for Notice of Unavailability of COBRA Continuation Coverage
- Enter the name and address of the employee, spouse or dependent.
- Enter the date notice was received from the employee, spouse or dependent.
- Enter the name of the group health plan.
- Enter the qualifying event or second qualifying event (e.g., divorce, legal separation,
cessation of dependent status, disability determination).
- Insert either "extended continuation coverage" (if request is for coverage
pursuant to a second qualifying event or disability determination) or "continuation
coverage" (if request is for an initial qualifying event).
- Enter the name of the individual and/or dependent(s).
- Enter the reason coverage is not available, including any plan provisions, facts
and/or COBRA provisions that form the basis of the decision.
- Enter either “extended continuation coverage” or "continuation coverage", consistent
with item 5 above.
- Enter the date COBRA coverage terminated or will terminate.
- Enter plan contact information as indicated.