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					                                                                           Health Net Health Plan of Oregon, Inc.
                                   Group Pay COBRA Election/Premium Subsidy Attestation
                                                                   American Recovery and Reinvestment Act

  To elect COBRA continuation coverage, complete this election form and return it TO YOUR EMPLOYER.
  Under federal law, you have 60 days from the date your coverage terminates to decide whether or not you want to elect
  COBRA continuation.
  If you do not submit a completed election form within the required time period, you will lose your right to continuation
                                                                                                            th
  coverage. If you reject COBRA before the 60-day period ends, you can change your mind up until the 60 day. In such a
  case, your COBRA coverage will begin on the date we received your election form, not on the date your group coverage
  ended.


Employer Name                                                                                 Group No.

Employee Name                                                                                 Soc Sec No.

*** If you have previously elected COBRA and are applying for the ARRA subsidy, go to the Attestation on the next page ***

                                                 TYPE OF QUALIFYING EVENT
                18-Month                                       29-Month                                     36-Month
EMPLOYEE (AND DEPENDENT IF ANY)                 Disabled qualified beneficiary            DEPENDENT(S) LOSING COVERAGE DUE
LOSING COVERAGE DUE TO:                                                                   TO:
   Termination of employment                                    (Name)                          Divorce or legal separation
   Reduction in hours                       Attach copy of Notice of Award                      Medicare eligible subscriber
                                            from SSI                                            Death of subscriber
                                                                                                Loss of dependent-child status

Date of Qualifying Event: (Enter Date)
Coverage to Be Continued:                      (HMO, PPO, etc.)

  I have read the specific notice of my COBRA options as provided by the employer. I understand I am eligible to self-pay my
  present Health Net of Oregon group health coverage for up to the number of months allowed by federal law. My eligibility
  for COBRA continuation will end when I become entitled to Medicare or become covered by another group health plan
  (unless that plan limits my coverage for a pre-existing condition, and then only until the full pre-existing condition exclusion
  period has been served).

        Yes, I want to continue group medical insurance through COBRA.
           1.   I understand I must pay any required premium due to the Health Net Group Contract Holder (Employer) each
                month by the date specified by the Employer.
           2.   I wish to elect the COBRA option for:
                    SELF Only            SELF and INSURED FAMILY MEMBERS                            INSURED FAMILY MEMBERS
                    Medical Only          Dental Only                    Medical and Dental


   Signature                                                                             Date

       No, I am not interested in continuing group medical insurance through COBRA.


   Signature                                                                             Date

                             EMPLOYER – Retain original and send a copy of the entire form to Health Net

                                          Please list all dependents to be covered
                                                          th
        Health Net Health Plan of Oregon, Inc., 13221 SW 68 Parkway, Tigard, Oregon 97223 • 888-802-7001 • www.healthnet.com

  FR901-HNO Rev. 1/10                                                                                                Group Pay COBRA
                                                                                                                Required

Qualified Dependent Name                                                                  Soc Sec No.

Qualified Dependent Name                                                                  Soc Sec No.

Qualified Dependent Name                                                                  Soc Sec No.

Qualified Dependent Name                                                                  Soc Sec No.

Qualified Dependent Name                                                                  Soc Sec No.

      Another page is attached with required information for additional dependents.

  NOTE: A Domestic Partner, even an Oregon Registered Domestic Partner, is not eligible for federal COBRA
  continuation. The Federal Recovery and Reinvestment Act Premium Subsidy is not available for domestic partner
  coverage. The cost of coverage for a domestic partner will be included in the amount you must pay with respect to
  federal stimulus reimbursement.

     Attestation of Eligibility for the American Recovery and Reinvestment Act Premium Reduction
1. The loss of employment was involuntary                                                                     Yes          No
2. The loss of employment occurred on or after September 1, 2008 and on or
before February 28, 2010                                                                                      Yes          No
3. I elected (or am electing) COBRA continuation coverage
If “No,” you may still be eligible – see “Additional Election Period” below                                   Yes          No
4. I am NOT eligible for other group health plan coverage (or I was not eligible for
other group health plan coverage during the period for which I am claiming a
reduced premium eligibility)                                                                                  Yes          No
5. I am NOT eligible for Medicare (or I was not eligible for Medicare during the
period for which I am claiming a reduced premium eligibility)                                                 Yes          No
6. I am currently receiving employer contributions to pay my health care premiums
     If Yes, how much are you receiving?
     If Yes, when will contributions from your employer end?                                                  Yes          No

  I am making an election to exercise my right to the American Recovery and Reinvestment Act Premium Reduction for
  myself or myself and my dependents, as shown on the first page of this form. To the best of my knowledge, all of
  the answers I have provided on this form are true and correct.

  Signature

  Relationship to Employee

  Date


  Additional Election Period

  If your COBRA continuation coverage relates to an involuntary loss of employment from September 1, 2008 through
  February 16, 2009 and:
       • you were eligible for, but did not elect COBRA continuation coverage, OR
       • you elected but then discontinued COBRA coverage
  you may have the right to have an additional 60-day election period. You should receive a new election notice with
  an Election Form which you must complete and return instead of this election form. If you believe you should have
  received this additional notice but did not, contact your employer.




                                                                     th
          Health Net Health Plan of Oregon, Inc., 13221 SW 68 Parkway, Tigard, Oregon 97223 • 888-802-7001 • www.healthnet.com

  FR901-HNO Rev. 1/10                                                                                               Group Pay COBRA
  Dependent Continuation Election / Attestation
  Use this section of the form when only one dependent is enrolling for COBRA.

  NOTE: A Domestic Partner, even an Oregon Registered Domestic Partner, is not eligible for federal COBRA continuation. The Federal Recovery and
  Reinvestment Act Premium Subsidy is not available for domestic partner coverage. The cost of coverage for a domestic partner will be included in
  the amount you must pay with respect to federal stimulus reimbursement.
                                                                                                                              Required

Qualified Dependent Name:                                                                            Soc Sec No.

                                                     TYPE OF QUALIFYING EVENT
                 18-Month                                             29-Month                                       36-Month
DEPENDENT LOSING COVERAGE DUE                         Disabled qualified beneficiary                DEPENDENT LOSING COVERAGE DUE
TO:                                                                                                 TO:
  Employee termination of                         Attach copy of Notice of Award
                                                                                                        Divorce or legal separation
employment                                        from SSI
  Employee reduction in hours                                                                           Medicare eligible subscriber
                                                                                                        Death of subscriber
                                                                                                        Loss of dependent-child status

Date of Qualifying Event: (Enter Date)

  I have read the specific notice of my COBRA options as provided by the employer. I understand I am eligible to
  self-pay my present Health Net of Oregon group health coverage for up to the number of months allowed by
  federal law. My eligibility for COBRA continuation will end when I become entitled to Medicare or become
  covered by another group health plan (unless that plan limits my coverage for a pre-existing condition, and then
  only until the full pre-existing condition exclusion period has been served).

        Yes, I want to continue my group medical insurance through COBRA.
            1.   I understand I must pay any required premium to the Health Net Group Contract Holder (Employer)
                 each month by the date specified by the employer.
            2.   I wish to elect the COBRA option for:
                     Medical Only              Dental Only                    Medical and Dental


    Signature                                                                                     Date
                     Responsible adult must sign for under age dependent
 Relationship
 to Employee

           Attestation of Eligibility for the American Recovery and Reinvestment Act Premium Reduction

1. I elected (or am electing) COBRA continuation coverage
If “No,” you may still be eligible – see “Additional Election Period” above                                                Yes         No
2. I am NOT eligible for other group health plan coverage (or I was not eligible
for other group health plan coverage during the period for which I am claiming a
reduced premium eligibility)                                                                                               Yes         No
3. I am NOT eligible for Medicare (or I was not eligible for Medicare during the
period for which I am claiming a reduced premium eligibility)                                                              Yes         No
4. I am currently receiving employer contributions to pay my health care
          premiums
     If Yes, how much are you receiving?
     If Yes, when will contributions from the employer end?                                                                Yes         No
  I am making an election to exercise my right to the American Recovery and Reinvestment Act Premium Reduction. To
  the best of my knowledge, all of the answers I have provided on this form are true and correct.

  Signature                                                                    Date
                        Responsible adult must sign for underage dependent
                                                                 th
         Health Net Health Plan of Oregon, Inc., 13221 SW 68 Parkway, Tigard, Oregon 97223 • 888-802-7001 • www.healthnet.com

  FR901-HNO Rev. 1/10                                                                                                            Group Pay COBRA

				
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posted:9/16/2011
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