Get documents about "Cobra Tracking Spreadsheet
Description
Cobra Tracking Spreadsheet document sample
Document Sample
COBRA Implementation Checklist
Complete and sign COBRA Services Agreement
Complete and sign Business Associate Agreement
Complete COBRA census (excel spreadsheet is attached separately)
-Page 1: Employer and coverage information.
--Please fax all Age and Area rate tables to
(916) 366-7817
-Page 2: Active employee census
-Page 3: Qualified Beneficiaries in election period plus currently
Active COBRA participants
Sign Assignment of COBRA Administrator (insurance) on company letterhead for
each plan and return originals to COBRA-Plus Administrators by mail.
If possible, obtain online login and password for enrollment in applicable benefit
plans
All information must be received no later than 4 weeks prior to implementation date.
Along with the completed aforementioned items, please return this sheet to COBRA Plus
administrators. Please send your completed census via email to Kristie@cobra-plus.com. You
will be contacted to set web training on use of our on-line notification system. If at any time
during this process you have questions or concerns on the attached documents, census or our
services, please feel free to contact me by phone or email.
I look forward to working with you.
Kristie Plummer
COBRA Services Supervisor
(For COBRA Plus use only)
Setup employer and rates into administrative system
Import census data
Send Welcome Kit/COBRA coupons to current participants/QB
Send Assignment letters to carriers/prior administrator and establish administrative
procedures/payments
Contact client and train in administrative procedures
3090 Fite Circle, Suite 201Sacramento, CA 95827(916) 363-2101 ext. 229jdeyo@cobra-plus.com
(PLEASE PRINT ON YOUR COMPANY LETTERHEAD)
Assignment of COBRA Administrator
Date: ______/________/________
Insurance Carrier: _______________________________
Group Number: _________________________________
Employer Name: ________________________________
Employer Address: ______________________________
Employer City, State, ZIP: ________________________
COBRA Plus Administrators, Inc., has been assigned to assist us in COBRA administration, effective ______/_______/_______.
Please provide them any information necessary regarding our Plan(s), enrollment/termination, open enrollment, conversion plans, and
COBRA participant information. Please note that COBRA-Plus Administrators will now be billing any COBRA members directly for
COBRA Premiums. If you currently bill the COBRA members directly, please change to billing the group, effective the date above!
We further request the following as indicated:
Premium Billing Statements for COBRA Members are to be Mailed To / Premiums Paid By:
Employer
COBRA Plus Administrators, Inc.
COBRA-Plus Administrators
3090 Fite Circle, Suite 201
Sacramento, CA 95827
(PLEASE NOTE: Some insurance carriers may not allow the separation of group billing, and will require that all billing/payments be run through the employer. If you request
billing to COBRA-Plus, and it is not an option, you will be notified)
Provide COBRA Plus online account access for COBRA enrollment/Termination: Yes No
PLEASE NOTE: We also hereby request that any COBRA billing group number suffixes currently designated to bill directly
to the member should hereby be changed to the suffix designated to bill in accordance to the selections above.
The contact information for COBRA Plus Administrators, Inc. is:
James E. Deyo III, MBA, Vice President, jdeyo@cobra-plus.com
Kristie Plummer, CCA, COBRA Services Supervisor, Kristie@COBRA-Plus.com, ext 245
Michelle Tinio, CCA, Cobra Administrator, Michelle@COBRA-Plus.com , ext 222
COBRA Plus Administrators, Inc.
3090 Fite Circle, Suite 201- Sacramento, CA 95827
(916) 363-2101 - (916) 366-7817 fax
Signature ________________________________
Title: ________________________________
(PLEASE PRINT ON YOUR COMPANY LETTERHEAD)
Assignment of COBRA Administrator
Date: _____/________/_________
Current COBRA Administrator: _______________________________
Group Number: _________________________________
Employer Name: ________________________________
Employer Address: ______________________________
Employer City, State, ZIP: ________________________
COBRA-Plus Administrators, Inc., has been assigned to assist us in COBRA administration effective
_____/________/________. Please provide them any information necessary regarding our COBRA
participants/beneficiaries to make this a smooth transition. All questions/payments should be directed to
COBRA-Plus Administrators, Inc. as of the effective date above. Please identify, by email, any COBRA issues
with one of the administrators listed below.
We further request the following, as indicated, on the effective date:
COBRA Qualifying Event Report
COBRA Participant report including date paid thru
COBRA Termination Report
The contact information for COBRA Plus Administrators, Inc. is:
James E. Deyo III, MBA, Vice President, jdeyo@cobra-plus.com
Kristie Plummer, CCA – COBRA Services Supervisor, Kristie@COBRA-Plus.com
Michelle Tinio, CCA- COBRA Administrator, michelle@cobra-plus.com
COBRA Plus Administrators, Inc.
3090 Fite Circle, Suite 201
Sacramento, CA 95827
(916) 363-2101
(916) 366-7817 fax
Signature ________________________________
Title: ________________________________
BUSINESS ASSOCIATE AGREEMENT
This BUSINESS ASSOCIATE AGREEMENT (the “Agreement”) is entered into this _____________, by
and between _____________________________ (hereinafter the “Covered Entity”), and the undersigned
(hereinafter the “Business Associate”).
WHEREAS, the Business Associate has been retained by the Covered Entity to perform certain plan-
related services as part of its Organized Health Care Arrangement (OHCA) on its behalf.
WHEREAS, in connection with the Business Associate’s provision of services, the Covered Entity may
disclose to the Business Associate information that is deemed to be “Protected Health Information” by the
Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (“HIPAA”).
WHEREAS, Covered Entity and Business Associate intend to protect the privacy and provide for the
security of Protected Health Information disclosed to Business Associate in compliance with HIPAA.
THEREFORE, the parties agree to enter into this Agreement to govern the disclosure of Protected
Health Information by the Covered Entity to the Business Associate and the treatment accorded to this
Protected Health Information by the Business Associate.
Definitions.
For purposes of this Agreement:
“Business Associate” will include the Business Associate and all successors and assigns,
affiliates, subsidiaries (as applicable), and related companies of the Business Associate.
“Designated Record Set” will have the same meaning given to the term “designated record set”
in 45 C.F.R. 164.501.
“Individual” will have the same meaning as the term “individual” in 45 C.F.R. §164.501 and will
include a person who qualifies as a personal representative in accordance with 45 C.F.R.
§164.502(g).
“Privacy Rule” will mean the Standards for Privacy of Individually Identifiable Health Information
at 45 C.F.R. Part 160 and Part 164, Subparts A and E.
“Protected Health Information” will have the same meaning as the term “protected health
information” in 45 C.F.R. §164.501, limited to the information created or received by the
Business Associate from or on behalf of the Covered Entity.
“Representative” will include the Business Associate’s managing members (as applicable),
employees, general partners (as applicable) and financial and legal advisors.
“Required by Law” will have the same meaning as the term “required by law” in 45 C.F.R. §
164.501.
“Secretary” will mean the Secretary of the Department of Health and Human Services or his
designee.
1. Confidentiality. At all times, both during and after the termination of its relationship with the Covered
Entity for any reason, the Business Associate and its Representatives will not use, disclose, or give others any
of the Protected Health Information in any manner whatsoever, except as provided in paragraphs 2 and 3 of
this Agreement, and will hold and maintain the Protected Health Information in confidence. The Business
Associate will ensure that appropriate safeguards are in place to prevent the use or disclosure of the Protected
Health Information other than as permitted by this Agreement.
2. Permitted Uses and Disclosures.
(a) Except as otherwise limited in this Agreement, the Business Associate may
use or disclose Protected Health Information on behalf of the Covered Entity
for the following purposes:
To provide services under the Consolidated Omnibus Reconciliation Act (COBRA)
(b) At the request of the Covered Entity, the Business Associate agrees to provide access to the
Protected Health Information that it maintains in Designated Record Sets to the Individual to whom the
Protected Health Information relates in accordance with 45 C.F.R. § 164.524. The Business Associate further
agrees to document any disclosures of Protected Health Information and the information related to such
disclosures to respond to an accounting of disclosures of Protected Health Information, if requested by the
Covered Entity, in accordance with 45 C.F.R. §164.528, and to provide such documentation to the Covered
Entity as it may request from time to time. Furthermore, at the request of the Covered Entity, the Business
Associate agrees to make amendments to Protected Health Information that it maintains in a Designated
Record Set as directed by the Covered Entity and to incorporate any amendments to Protected Health
Information in accordance with 45 C.F.R. § 164.526. Notwithstanding the foregoing, the Covered Entity will not
request that the Business Associate use or disclose Protected Health Information in any manner that would not
be permissible under the Privacy Rule, if such disclosure or use were done by the Covered Entity itself.
(c) The Business Associate may disclose Protected Health Information to its agents or subcontractors
with a bona fide need to know such Protected Health Information, but only if, prior to such disclosure, such
agents or subcontractors provide reasonable assurances that they will agree to the same restrictions and
conditions that apply to the Business Associate with respect to such Protected Health Information.
3. Required Disclosures and Use. The Business Associate may disclose the Protected Health Information
revealed to it by the Covered Entity if and to the extent that Law or court order requires such disclosure.
Further, the Business Associate agrees to make its internal practices, books, and records, including policies
and procedures, relating to the use and disclosure of Protected Health Information received from, or created or
received by the Business Associate on behalf of the Covered Entity [available to the Covered Entity], or to the
Secretary, as requested by the Covered Entity or designated by the Secretary, for purposes of the Secretary
determining the Covered Entity’s compliance with the Privacy Rule.
4. Required Notice to the Business Associate. In accordance with 45 C.F.R. §164.520, and to the extent
that such a limitation may affect the Business Associate’s use or disclosure of Protective Health Information,
the Covered Entity will notify the Business Associate of any limitation(s) in its notice of privacy practices of the
Covered Entity, including, without limitation, any changes in, or revocation of, permission by an Individual to
use or disclose Protected Health Information. Covered Entity will also notify the Business Associate of any
restriction to the use or disclosure of Protected Health Information that Covered Entity has agreed to in
accordance with 45 C.F.R. § 164.522, to the extent that such restriction may affect the Business Associate’s
use or disclosure of Protected Health Information.
5. Required Notice to the Covered Entity. The Business Associate will report to the Covered Entity any
use or disclosure of Protected Health Information otherwise than as provided by this Agreement within [ten]
days of becoming aware of such use or disclosure.
6. Disclosure to Employees of the Covered Entity or Plan Sponsor.
(a) The Covered Entity acknowledges and agrees that the Business Associate shall only disclose
PHI in its possession to the following employees (Designated Persons) in accordance with 45
C.F.R. § 164.504(f), and that such disclosures are solely for purposes of carrying out plan
administration functions that the Plan Sponsor performs for the Plan ( LIST SUCH PERSONS BY
NAME OR POSITION—GENERALLY, IN-HOUSE HUMAN RESOURCE AND/OR ACCOUNTING
PROFESSIONALS INVOLVED WITH BENEFIT ADMINISTRATION):
Name Title
_________________________ _____________________________
_________________________ _____________________________
_________________________ _____________________________
(b) Covered Entity agrees to timely notify Business Associate in writing of any changes to
the names or positions of employees listed in subsection (a) as Designated Persons.
Business Associate shall have no duty to inquire whether the list of Designated Persons
is accurate.
(c) Covered Entity/Plan Sponsor shall indemnify and hold harmless Business Associate
(and its employees) for any and all liability Business Associate may incur as a result of
any improper use or disclosure of PHI by the Covered Entity, Plan Sponsor or a
Designated Person(s).
Term/Termination.
7.1 Term. This Agreement shall be effective as of the later of April 14, 2004 or the date set
forth above, and shall terminate as provided in Section 6.2 or upon thirty (30) days written notice by
the Covered Entity or the Business Associate.
7.2 Termination for Cause. Upon Covered Entity’s knowledge of a material breach of this
Agreement by Business Associate, the Covered Entity shall either:
(1) Provide an opportunity for Business Associate to cure the breach or end the
violation and/or terminate this Agreement. If Business Associate does not cure the
breach or end the violation within the time specified by the Covered Entity; then
(2) Immediately terminate this Agreement if Business Associate has breached a
material term of this Agreement and cure is not possible; or
(3) If neither termination nor cure is feasible, Covered Entity shall report the violation to
the Secretary.
7.3 Effect of Termination.
(1) Upon termination of this Agreement, for any reason, Business Associate shall
return or destroy all Protected Health Information received from Covered Entity, or
created or received by Business Associate on behalf of Covered Entity. This
provision shall apply to Protected Health Information that is in the possession of
subcontractors or agents of Business Associate. Business Associate shall retain no
copies of the Protected Health Information.
(2) In the event that Business Associate determines, in its sole discretion, that returning
or destroying the Protected Health information is infeasible, Business Associate
shall provide to Covered Entity notification of the conditions that make return or
destruction infeasible. In the event that Business Associate determines that return
or destruction of the Protected Health Information is infeasible, Business Associate
will continue to extend the protections of this Agreement to such Protected Health
Information and limit further uses and disclosures of such Protected Health
Information to those purposes that make the return or destruction infeasible, for so
long as the Business Associate maintains such Protected Health Information. If it is
determined that the Protected Health Information is to be returned to Covered
Entity, then Covered Entity agrees to pay to Business Associate it’s normal hourly
rate for the time and handling involved.
8. No Third Party Beneficiaries. Nothing express or implied in this Agreement is intended to confer, nor
shall anything herein confer, upon any person other than Covered Entity, Business Associate and their
respective successors or assigns, any rights, remedies or obligations whatsoever.
9. Successors and Assigns. This Agreement and each party’s obligations hereunder will be binding on
the representatives, assigns, and successors of such party and will inure to the benefit of the assigns and
successors of such party; provided, however, that the rights and obligations of the Business Associate
hereunder are not assignable.
10. Notices. All notices, requests, consents and other communications hereunder will be in writing, will be
addressed to the receiving party’s address set forth below or to such other address as a party may designate
by notice hereunder, and will be either (i) delivered by hand, (ii) made by facsimile transmission, (iii) sent by
overnight courier, or (iv) sent by registered or certified mail, return receipt requested, postage prepaid.
If to the Covered Entity: _________________________
_________________________
_________________________
Facsimile:_________________
If to the Business Associate: COBRA Plus Administrators, Inc..
3090 Fite Circle, Ste.201
Sacramento, CA 995827
Facsimile: 916-363-2180
1. Entire Agreement. This Agreement embodies the entire agreement and understanding between the
parties hereto with respect to the subject matter hereof and supersedes all prior oral or written agreements and
understandings relating to the subject matter hereof. No statement, representation, warranty, covenant or
agreement of any kind not expressly set forth in this Agreement will affect, or be used to interpret, change or
restrict, the express terms and provisions of this Agreement.
12. Modifications and Amendments. The terms and provisions of this Agreement may be modified or
amended only by written agreement executed by the parties hereto and any such amendment will comply with
the requirements of the Privacy Rule and the Health Insurance Portability and Accountability Act of 1996, Pub.
L. No. 104-191.
13. Severability. The parties intend this Agreement to be enforced as written. However, (i) if any portion
or provision of this Agreement will to any extent be declared illegal or unenforceable by a duly authorized court
having jurisdiction, then the remainder of this Agreement, or the application of such portion or provision in
circumstances other than those as to which it is so declared illegal or unenforceable, will not be affected
thereby, and each portion and provision of this Agreement will be valid and enforceable to the fullest extent
permitted by law; and (ii) if any provision, or part thereof, is held to be unenforceable because of the duration of
such provision, the Covered Entity and the Business Associate agree that the court making such determination
will have the power to reduce the duration of such provision, and/or to delete specific words and phrases, and
in its reduced form such prevision will then be enforceable and will be enforced.
14. Interpretation. The parties hereto acknowledge and agree that both (i) the rule of construction to the
effect that any ambiguities are resolved against the drafting party and (ii) the terms and provisions of this
Agreement, will be construed fairly as to all parties hereto and not in favor of or against a party, regardless of
which party was generally responsible for the preparation of this Agreement.
15. Headings and Captions. The headings and captions of the various subdivisions of this Agreement are
for convenience of reference only and will in no way modify, or affect the meaning or construction of any of the
terms or provisions hereof.
16. No Waiver of Rights, Powers and Remedies. No failure or delay by a party hereto in exercising any
right, power or remedy under this Agreement, and no course of dealing between the parties hereto, will operate
as a waiver of any such right, power or remedy of the party. No single or partial exercise of any right, power or
remedy under this Agreement by a party hereto, nor any abandonment or discontinuance of steps to enforce
any such right, power or remedy, will preclude such party from any other or further exercise thereof or the
exercise of any other right, power or remedy hereunder. The election of any remedy by a party hereto will not
constitute a waiver of the right of such party to pursue other available remedies. No notice to or demand on a
party not expressly required under this Agreement will entitle the party receiving such notice or demand to any
other or further notice or demand in similar or other circumstances or constitute a waiver of the rights of the
party giving such notice or demand to any other or further action in any circumstances without such notice or
demand. The terms and provisions of this Agreement may be waived, or consent for the departure therefrom
granted, only by written document executed by the party entitled to the benefits of such terms or provisions.
No such waiver or consent will be deemed to be or will constitute a waiver or consent with respect to any other
terms or provisions of this Agreement, whether or not similar. Each such waiver or consent will be effective
only in the specific instance and for the purpose for which it was given, and will not constitute a continuing
waiver or consent.
17. Governing Law. This Agreement will be governed by and construed in accordance with the laws of the
State of California.
18. Attorney’s Fees. If any action at law or in equity is brought to enforce or interpret the provisions of this
Agreement, the prevailing party in such action will be entitled to reimbursement for reasonable attorneys’ fees
and costs.
19. Counterparts. This Agreement may be signed in counterparts, which together will constitute one
agreement.
IN WITNESS WHEREOF, the parties have caused this Agreement to be signed by their duly authorized
representatives or officers, effective as of the date first listed above in the preamble to this Agreement.
COVERED ENTITY: ______________________________
By_________________________________
BUSINESS ASSOCIATE: COBRA Plus Administrators, Inc.
By_________________________________
**This document is presented as a sample only. Covered Entity’s legal counsel should review all such documents. COBRA
Plus Administrators, Inc. assumes neither responsibility nor liability for the accuracy or legality of this document.**
COBRA Service Agreement
Agreement made this ________ day of _______________ by and between:
___________________________ (hereinafter referred to as “Employer”)
and
COBRA Plus Administrators, Inc. 3090 Fite Circle, Ste. 201, Sacramento, CA 95827 (hereinafter
referred to as “COBRA PLUS” ).
WHEREAS, the Employer has resolved to retain COBRA Plus to assist with certain compliance
requirements of the Consolidated Omnibus Reconciliation Act of 1985 (COBRA) and the Health
Insurance Portability and Accountability Act of 1996 (HIPAA), and any amendments thereto, herein
referred to as “the Acts”.
NOW THEREFORE, in consideration of the premises and mutual promises contained herein, the
parties agree as follows:
The employer hereby retains COBRA Plus to assist its benefit plans Administrator (as defined by the
Acts) to provide notifications and services as indicated below:
(Optional) Initial notification by First Class Mail with proof of mailing to all employees who are
participants under Covered Benefit Plans on the effective date of this agreement.
Initial notification by First Class Mail with Proof of Mailing to all employees who become
participants under Covered Benefit Plans after the date of this agreement.
Qualifying Event Notification by First Class Mail with Proof Of Mailing to Qualified Beneficiaries
for Qualifying Events occurring after the effective date of this agreement.
HIPAA Certificate of Coverage Notification. Initial HIPAA Certificate included with COBRA
Qualifying Event Notification and Second HIPAA Certificate following termination of COBRA.
Update Notifications by First Class Mail to Covered Employees, COBRA Participants, and/or
Qualified Beneficiaries as may be required by amendments to the acts and the regulations, or
changes to covered benefit plans.
Maintain COBRA information on a secure website for employer access (www.myrsc.com) –No
charge if greater than 50 active insured’s, available at nominal fee if few than 50.
Termination Notification upon non-payment of premium or end of COBRA term.
Billing, tracking, premium collection, and remittance to the Employer. COBRA Plus will retain
any administrative fees added to premiums.
Establishment of all Benefit Plans/Rates on COBRA Plus systems
COBRA Procedures Manual provided to client.
Maintain computer and/or physical records of all notices sent. Qualifying Event notices will be
recorded on ledger books approved by the U.S. Postal Service. At COBRA Plus’s option, filled
ledger books will be archived for a period of seven (7) years from the date of the last entry, or
forwarded to the employer for safekeeping.
Maintain a database of qualifying beneficiaries to whom notifications have been sent. Data will
include all pertinent information reported by the employer. Data will be purged from computer
records approximately 90 days following the deadline for response by the qualifying
beneficiary.
Provide employer with confirmation of all notifications sent. Confirmation reports shall include
the reason for the notice, qualifying event, the qualifying date, the notification date, and the
deadline for any response by the qualifying beneficiary.
Notify the Employer of any discrepancies or conditions it discovers during the course of its
operations which may require action by the Employer.
Notify the Employer of known changes or updates relating to compliance with the Act.
Provide New Hire, Qualifying Event and Reason for Change forms to be used by the employer
Employer Responsibilities and Duties:
At least two weeks prior to commencement of services under this agreement, Employer shall submit
to COBRA Plus the following information:
Complete census of all employees who are active participants in covered health plans. This
information shall be submitted in a manner prescribed by COBRA Plus, in order to obtain all
data necessary to effectively and legally administer all covered plans. Unless other
arrangements are made, this information will be submitted by Employer in an electronic format
as specified by COBRA Plus.
COBRA Plus shall provide to Employer a questionnaire regarding information on all qualified
health plans maintained by Employer. Signed questionnaire to be returned with census above.
Employer shall submit to COBRA Plus a signed completed data sheet (furnished by COBRA
Plus) for each of the following: COBRA Participants, Qualifying Beneficiaries who have been
notified and are in the election period, and Qualifying Beneficiaries who have not been notified.
Following commencement of services under this agreement, Employer will notify COBRA Plus in
writing within 10 days of the date it has knowledge of the following:
Employees who have become eligible for and elected a covered benefit. Initial Notification
must be provided to all employees who elect a covered benefit.
Qualifying Events
Death of a covered employee
Termination of employment
Reduction of work hours which cause a loss of coverage
Divorce or legal separation of a covered employee.
A covered employee’s entitlement to benefits under title XVIII of the Social Security Act
(Medicare)
A dependent of a covered employee ceasing to be a dependent
Changes to covered health plans (including insurers, rates, or benefits). Notices of change
must be sent to COBRA Participants and Qualifiers in their election period and during Open
Enrollment.
Representations, Warranties and Understandings:
Employer warrants and represents that it is the legal Plan Administrator and sole fiduciary of
the Plan or Plans covered by this Agreement, and shall not require any bond or security of
COBRA Plus in the performance of its duties under this Agreement.
Employer reserves full authority to make all decisions regarding its COBRA administration,
Including those duties and responsibilities delegated to COBRA Plus by this Agreement. In
accordance with this Agreement, COBRA Plus will serve as a Service Provider under the
direction of the Plan Administrator (Employer), but will not act as the Plan Administrator.
Employer shall take any and all necessary action and execute any and all necessary
documents to authorize COBRA Plus to perform its functions and duties pursuant to this
Agreement.
Employer agrees to timely provide COBRA Plus with information and/or documentation
reasonably requested by COBRA Plus which is necessary for COBRA Plus to fulfill the terms
and conditions of this agreement.
Employer agrees to indemnify, defend, and hold COBRA Plus, its representatives and
employees harmless and to reimburse COBRA Plus for any losses COBRA Plus might suffer,
of whatever nature or whatever source, except for negligence or omissions on the part of
COBRA Plus Administrators, Inc., including but not limited to Employer’s failure to comply with
its representations and warranties and with the terms and conditions of this Agreement, or to
otherwise timely provide COBRA Plus with information and/or documentation reasonably
required by COBRA Plus that is necessary for COBRA Plus to fulfill the terms and conditions
of this Agreement. An exception to this hold harmless agreement is conditions that result from
omissions or negligence on the part of COBRA Plus Administrators, Inc. COBRA Plus
Administrators, Inc. holds the Employer, Insurance Carrier(s) and Representatives/Brokers
harmless for omissions or negligence on the part of COBRA Plus Administrators, Inc.
The Fees specified in Exhibit A shall be paid to COBRA Plus Administrators, Inc.
Term of this Agreement:
Services pursuant to this Agreement shall commence on: _____________ and continue until
terminated by either party.
This Agreement shall automatically renew for one year terms on the expiration date stated above at
the rates stated below unless modified in writing by mutual agreement of both parties prior to the
expiration date.
This Agreement may be terminated by either party for reasonable cause upon 30 days written notice
stating such reasonable cause. Reasonable cause shall include, but not be limited to the following:
Bankruptcy or insolvency of either party
Termination of broker agreement by any party to this agreement (if broker pays all or part of
the administrative fee). In exchange for the broker paying for all/part of the fees to this
agreement, termination of said broker agreement will terminate this contract and cannot be
entered again with the above employer for a period of 1 year at full contract rates.
Change in statutes or regulations which eliminate or substantially modify the requirements for
COBRA Notification
Either party is suspended or restricted from performance by Federal or State regulatory
authority
Either party fails to comply with the provisions of this agreement
The employer fails to pay fees in accordance with fee schedule
This is the sole agreement between the parties, and shall not be amended or modified except by
written agreement between the parties. This agreement shall be binding upon both parties, its
successors or assignees, and shall be interpreted under the laws of the State of California.
The undersigned signatory for the Employer hereby warrants and represents that he/she is duly
authorized by the Employer to execute this Agreement on behalf of the Employer, and that he/she
has read the Agreement in its entirety.
We have received Exhibit A which outlines COBRA Plus Administrators, Inc. fees for services
provided. We further request the following optional services:
Initial/General Notices to all currently covered employees
Web seminar
Employer:
For: _____________________________
By: ________________________________
Date: _____________ Title: _______________________
For: COBRA Plus Administrators, Inc.
By:
Date: _______________ Title: Vice President
HIPAA Security Rule Amendment to Business Associate Agreement
This amendment to the business associate agreement is made between Pacific Benefit Consultants Inc. and/or COBRA
Plus Administrators, Inc. (the “Business Associate”) and ________________________(the “Covered Entity).
WHEREAS, the Business Associate and Covered Entity have entered into a Business Associate Agreement as required
under the Heath Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations for
Standards of Privacy of Individually Identifiable Health Information, 45 CFR part 160 and part 164 subparts A and E; and
WHEREAS, the U.S. Department of Health and Human Services (HHS) has issued final regulations pursuant to the
Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA),
governing the security of electronic health information (EPHI) obtained, created or maintained by or from covered
entities; and
WHEREAS, the Business Associate and its employees, affiliates, agents or representatives access, create, obtain, or
maintain PHI and EPHI in the conduct of their obligation to the Covered entity;
NOW, THEREFORE, the Business Associate and Covered Entity amend any prior Business Associate Agreement to
include the following to comply with the HIPAA Security Rule, 45 CFR 164, subpart C.
1. Business Associate shall implement and maintain appropriate administrative, physical, and technical measures to
reasonably and appropriately protect the integrity, confidentiality and availability of PHI and EPHI that it may
receive or maintain as a result of the relationship between the Business Associate and Covered Entity.
2. The Business Associate shall ensure that any agent, affiliate, or representatives implement administrative,
physical, and technical measures to reasonably and appropriately protect the integrity, confidentiality and
availability of PHI and EPHI.
3. The Business Associate shall promptly notify the Covered Entity of any “security incident” which it becomes
aware of as defined in the HIPAA Security Rule.
4. The Business Associate agrees that all security measures will be consistent with 45 CFR 164, subpart C as of the
effective date of the regulation.
5. The Business Associate Agreement and HIPAA Security Rule Amendment may be terminated by the Covered
Entity if the Covered Entity determines that the Business Associate violated a material provision of the
Agreement or this Amendment.
IN WITNESS WHEREOF, the parties hereto have executed this Amendment effective April 20, 2006.
Business Associate Covered Entity
Pacific Benefit Consultants, Inc. and/or
COBRA Plus Administrators, Inc. _______________________
Company Name
________________________
James E. Deyo, III Signature
Principal/Director of Marketing ________________________
April 19, 2006 Title
________________________
Date
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