COBRA Management System

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A. 39K	COBRA Initial Notice to Health Plan Participants Mailed to employees within 90 days of the effective date of new health plan coverage. Also mailed to a spouse and/or dependent(s) whose address is different from the employee's. Contains COBRA Qualifying Event Form (Doc H).
B. 42K	COBRA Offer to Employees Letter to offer COBRA to employees who lose coverage due to a reduction of hours or termination of employment. Includes COBRA Qualifying Event Form (Doc. H).
B1. 24K	COBRA Election Form for Employees Mailed with Document B. This is the accompanying Election Form that must be returned by the eligible employee in order to receive COBRA coverage.
C. 35K	COBRA offer to Spouses & Dependents Mailed to a spouse and/or dependent child(ren) who will be loosing health plan coverage because of a qualifying event other than an employee's termination or reduction of hours (i.e. divorce, legal separation, death or Medicare entitlement of employee). Includes COBRA Qualifying Event Form (Doc. H).
C1. 27K	COBRA Election Form for Spouses & Dependents Mailed with Document C. This is the accompanying Election Form that must be returned by the eligible spouse and/or dependent(s) in order to receive COBRA coverage.
D. 36K	COBRA offer to Former Dependents Mailed to child(ren) who will be loosing health plan coverage becuase they are no longer considered a dependent under the terms of the employee's health plan. Includes COBRA Qualifying Event Form (Doc. H).
D1. 25K	COBRA Election Form for Former Dependent Children Mailed with Document D. This is the accompanying Election Form that must be returned by the eligible dependent in order to receive COBRA coverage.
E. 21K	COBRA Not Available Notification Mailed to anyone who fails to return Document H within the required timeframe. This letter informs the employee, spouse, and/or dependent that they are not eligible for COBRA coverage because they failed to notify employer of a qualifying event within the 60-day timeframe.
F. 20K	COBRA Conversion Notification Mailed to COBRA participants prior to their COBRA coverage expiration date. It states the date of expiration and explains the right to convert their COBRA plan to an inidvidual direct-pay plan.
G. 21K	COBRA Cancellation Notice Mailed to COBRA participants whose coverage is expiring prior to the original coverage period (18, 29 or 36 months). It states the reason for the early cancellation and the new effective date of COBRA coverage cancellation.
K. 22K	COBRA Social Security Extension Mailed to employees who accepted COBRA as a result of a termination or reduction of hours and subsequently qualifies for Social Security Disability (due to the employer's receipt of a Document H with a disability notification). It offers the COBRA-participating employee an 11-month extension of COBRA coverage (from 18 to 29 months).
H. 22K	COBRA Qualifying Event Form Included with Documents B, C and D. It is mailed to anyone covered under an employer's health plan. It must be returned to the employer in order to become eligible for COBRA. It officially notfies the Employer of a qualifying event such as a divorce, separation, loss of dependent status, legal separation, etc.
I. 21K	Loss of Health Plan Coverage for Spouses & Dependents; COBRA Not Available Mailed to a spouse and/or dependent(s) who are no longer covered by the employee's health plan because the employee voluntarily removed them from the health plan. As the employee voluntarily cancelled the coverage, they are not eligible for COBRA (a qualifying event did not occur).
J. 44K	COBRA Tax Credit Notice for Employees Mailed with Documents B and B1 to employees who lose coverage due to a lay-off and may be eligible for the Federal Trade Adjustment Assistance (TAA) Program.
L. 21K	COBRA Secondary Event Notice for Spouses & Dependents Mailed to non-employee COBRA participants (i.e. spouses and/or dependents) upon the employer's receipt of Document H that provides notification of a second event. It offers the COBRA participant an 18-month extension of COBRA coverage (from 18 to 36 months).
M. 24K	Incorrect Premium Letters for COBRA Participants Mailed to COBRA Participants who either underpay their monthly premium, or whose payment was returned due to insufficient funds. It outlines the procedure that must be adhered to in order to make timely payment and retain coverage.
Tracking & Auditing Documents for Employers
X2 25K	Compliance Checklist for COBRA Participants A checklist of COBRA mailings/activities to assist employers with tracking of an individual's COBRA activity. This form is not mailed. Two copies should be printed for every person who accepts COBRA; one is retained in the employee's file and one with the employer's COBRA records.
43K	COBRA Master Log A system developed to assist employers with tracking aggregate COBRA activity. The form can be printed and retained with the employers COBRA records.
34K	COBRA Administrative Forms COBRA Telephone Call Log, I.R.S. COBRA Administration Audits, Monthly COBRA Audit Report These three documents assist employers with documenting and auditing COBRA administrative duties and provide important back-up if disputes occur.
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Tracking & Auditing Documents for Employers