Model Notice New Cal-COBRA Continuation Coverage Rights

Model Notice: New Cal-COBRA Continuation Coverage Rights (For use where coverage is subject to Cal-COBRA continuation requirements during the period that begins with September 1, 2008 and ends with the effective date of AB 23 (Jones – 2009) [Enter date of notice] Dear: [Identify the qualified beneficiary(ies), by name or status] This notice has important information about your health care coverage through {Name of Health Plan} Please read it carefully. You May Be Eligible for Reduced Cal-COBRA Premiums A new law reduces the Cal-COBRA premiums for up to 9 months, in some cases. The new law is the federal American Recovery and Reinvestment Act of 2009 (ARRA). We sent you this notice because you became eligible for Cal-COBRA between September 1, 2008 and December 31, 2009. To find out if you are eligible for the premium reduction, you should read this notice and the attached documents carefully. You May Have Another Chance to Enroll in Cal-COBRA (A Special Election Period) You may have the right to another 60-day period when you can elect (enroll in) Cal-COBRA. This additional chance to enroll is only available if you are eligible for the premium reduction. You may get an additional 60-day period if you were eligible for, but did not elect, Cal-COBRA coverage. You may also get it if you elected but then stopped your Cal-COBRA coverage. You may get an extension on your election period, if it has not ended. For more information, please read the attached page called “Special Election Period for CalCOBRA.” To enroll in Cal-COBRA during the additional 60-day period, you MUST complete and return a new “Cal-COBRA Election Form” along with your “Application for Premium Reduction” form. How to Apply for Premium Reduction and Cal-COBRA If you think that you are eligible, fill out the “Application for Premium Reduction” and the “Cal-COBRA Election Form.” Return these 2 forms to {Health Plan} within 60 days of the date of this notice. If you are not eligible for the premium reduction, you will not be eligible for the Special Election Period. Note, you may have dependents who qualify for Cal-COBRA coverage but do not qualify for premium reduction (examples include domestic partners, same-gender spouses, and grandchildren) If you are not eligible for the premium reduction and your original Cal-COBRA election period has not ended, you may still elect Cal-COBRA. Complete the attached “Cal-COBRA Election Form” and send it to us. If you do not know if your original election period has ended, call us at the number listed below. Each person who was enrolled on the group health plan may be able to enroll in Cal-COBRA during the original election period. When Cal-COBRA Starts If you are eligible, your Cal-COBRA coverage will start on the first day of the month after you send your election forms, in most cases (special rules may apply if you or your family member involuntarily lost a job after February 17, 2009—see the page entitled “Special Election Period for Cal-COBRA”). You must pay all premiums from that date forward. You can keep Cal-COBRA for up to 36 months from the date that you first became eligible for CalCOBRA. The ARRA premium reduction lasts for up to 9 months, if you are eligible for it. Premium Information {Alternative 1: For use when the plan is providing an estimated premium} The usual cost of Cal-COBRA premiums is 110% of the applicable group rate. The estimated premium for you and your dependents is $ {insert estimated premium or last known premium}. Please note this is an estimate only and may change. Call {Name of Health Plan} to find the exact rate(s) for you and your dependents. If you are eligible for premium reduction, your premium can be reduced to 35 percent of the usual cost. The premium reduction lasts for up to 9 months. You do not have to send any payment with your Cal-COBRA Election Form. Information about payment is attached after the form. You may have dependents who are eligible for Cal-COBRA coverage but not for premium reduction. Domestic partners, same-gender spouses and grandchildren are not eligible. You must pay the full amount of their premiums. Call {Name of Health Plan} at (XXX) XXX-XXXX for more information.} {Alternative 2: For use when the plan is providing the exact premium} { The usual cost of Cal-COBRA cove premiums is 110% of the applicable group rate. Your premium is listed in the box below. If you are eligible for the reduction, your premium can be reduced to 35 percent of the usual cost. The premium reduction lasts for up to 9 months. You do not have to send any payment with your Cal-COBRA Election Form. Information about payment is attached after the form. You may have dependents who are eligible for Cal-COBRA coverage but not for premium reduction. Domestic partners, same-gender spouses and grandchildren are not eligible for premium reduction. You must pay the full amount of their premiums. Call {Name of Health Plan} at (XXX) XXX-XXXX for more information.} Your Premiums Without premium reduction: The premium you would $ pay for Cal-COBRA if you are not eligible for the premium reduction. With premium reduction: The premium you would $ pay for Cal-COBRA if you are eligible for the premium reduction. {Health plan to insert premium information for the full 110% of premium and 35% of the premium. The plan may show this amount for the family or for each person who may be eligible for premium reduction.} Verification of Eligibility for Premium Reduction You must show that you or your family member had an involuntary job loss. This is also called an “involuntary termination of employment.” You may submit a letter or notice from your former employer as proof. {Any of the following alternative paragraphs may be used as applicable if the plan must obtain the employer’s attestation. If the plan can accept the employee’s attestation, this section can be deleted.} {Alternative 1: Use if the plan will seek verification from the employer after the qualified beneficiary has submitted their election form and the health plan will seek the verification directly from the employer. {Name of Health Plan} may ask your former employer to state in writing (verify) that you were involuntarily terminated. Your former employer must respond within 10 calendar days from the date {Name of Health Plan} sends the request for proof. If you are denied the premium reduction, you have the right to a review.} {Alternative 2: For use when the plan will accept documents provided by the employer to the employee, the employee does not have them and the plan is directing the employee to obtain them from the employer.} {If you do not have any documents from your former employer showing you were involuntarily terminated, you must ask them to complete the attached form, “Verification of Involuntary Termination.” Your former employer must complete and sign the form and return it to {Name of Health Plan} within 10 calendar days. If you are denied the premium reduction, you have the right to a review.} {Alternative 3: For use when the plan wants the employee to seek verification from the employer even if the employee has documents.} {{Name of Health Plan} will review your proof of involuntary termination. Also, you must send the attached form, “Verification of Involuntary Termination,” to your former employer. They must complete and sign it and return it to {Name of Health Plan} within 10 calendar days. If you are denied the premium reduction, you have the right to a review.} DO NOT wait for a reply from your former employer before you send the “Application for Premium Reduction” form and Cal-COBRA Election Form {or name of Plan’s Election Form} to {Name of health plan}. If you are denied the premium reduction, you have the right to a review. You May Also Be Able to Change Your Health Plan If you are eligible for the premium reduction, your former employer may allow you to change to a different plan than the plan that you had on your last day of employment. The premiums for the new coverage may not be more than the premiums for your original coverage. Call your former employer for information about the health plans you could choose, and the premiums. Call the plans for more information about fees and benefits. If you are able to change your health plan, you can use the attached form, “Application to Change Health Plans.” Your former employer must complete this form and send it to the new health plan within 90 days from the date of this notice, along with any other necessary information. If you have difficulty reading or understanding this notice, please call {name of health plan} at 1-xxx-xxx-xxxx. {TTY: 1-xxx-xxx-xxxx} CAL-COBRA ELECTION FORM {Alternatively, Plans may use their current Cal-COBRA Enrollment/Election Forms} I (We) elect Cal-COBRA continuation coverage as indicated below: Employee Information: Last Name: {Name of Health Plan} {ID and/or SSN}: Date of Qualifying Event: First Name: Group/Section No: MI: Type of Qualifying Event (check one – enter date): ____ Termination or reduction in hours (last day worked): ____/____/____ ____ Divorce or legal separation (date): ____/____/____ ____ Entitlement to Medicare benefits by the covered employee (event date): ____/____/____ ____ Loss by child of dependent eligibility (event date): ____/____/____ ____ Death of covered employee (date): ____/____/____ ____ Termination of domestic partnership (date): ____/____/____ Qualifying Elector Information: Last Name: {Name of health Plan][ID and/or SSN}: Address: Gender: M F Married: Yes No Yes No First Name: Date of Birth: Phone No.: Domestic Partner: Eligible for Medicare: Yes Yes No Phone No.: No MI: Have Other Health Coverage: {If known, indicate your Health Plan Personal Physician’s Name}: Signature Date Print Name List below all dependents eligible for coverage: Last Name: Relationship: Have Other Health Coverage: Yes No Relationship to individual(s) listed above First Name: Date of Birth: Eligible for Medicare: Yes No {If known, indicate Health Plan Personal Physician’s Name}: Phone No: Last Name: Relationship: Have Other Health Coverage: Yes No First Name: Date of Birth: Eligible for Medicare: Yes No Phone No: {If known, indicate Health Plan Personal Physician’s Name}: Last Name: Relationship: Have Other Health Coverage: Yes No First Name: Date of Birth: Eligible for Medicare: Yes No Phone No: {If known, indicate Health Plan Personal Physician’s Name}: Last Name: Relationship: Have Other Health Coverage: Yes No First Name: Date of Birth: Eligible for Medicare: Yes No Phone No: {If known, indicate Health Plan Personal Physician’s Name}: Please attach additional sheets if required. Important Information about Cal-COBRA What is Cal-COBRA continuation coverage? Cal-COBRA is a state law that protects your right to continue your health coverage after certain qualifying events, such as losing your job. This is called continuation coverage. Cal-COBRA applies to employers with fewer than 20 employees. Cal-COBRA protects the employee (or retired employee) covered under the group health plan. Cal-COBRA protects dependents’ right also, including the covered employee’s spouse or domestic partner, and the dependent children of the covered employee, spouse or domestic partner. Cal-COBRA continuation coverage is the same as the coverage for other Plan enrollees who are not receiving continuation coverage. Enrollees with Cal-COBRA will have the same rights as other Plan enrollees, including the right to change plans at open enrollment. Note that some dependents are eligible for Cal-COBRA continuation coverage, but are not eligible for the premium reduction under ARRA. Grandchildren, same-gender spouses and domestic partners are not eligible for the premium reduction. How long will Cal-COBRA continuation coverage last? Continuation coverage can last for up to 36 months from the date of the original qualifying event, as long as you continue to meet the other eligibility requirements. Note that the ARRA premium reduction described on the first page of this notice only lasts up to 9 months. How can you elect continuation coverage? To elect continuation coverage, you must complete and submit the Cal-COBRA Election Form. Examine your options carefully before you decline continuation coverage If you decline continuation coverage, your future rights under federal law will be affected. If you have a 63-day gap in health coverage, other group health plans can delay coverage for preexisting conditions. Electing continuation coverage may help prevent such a gap. You will lose the guaranteed right to purchase an individual health coverage that does not impose a preexisting condition exclusion, if you do not elect continuation coverage for the maximum time available to you. Remember, you have other enrollment rights under federal law You have the right to enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within 30 days after your group health coverage ends because of the qualifying event listed above. You will also have the same enrollment right at the end of continuation coverage if you get continuation coverage for the maximum time available to you. How much do my Cal-COBRA premiums cost me now? Your current monthly premiums for Cal-COBRA are based on the following rules: Cal-COBRA usually costs 110% of the group rate. This is the amount charged for the coverage for active employees or dependents under the group plan. If you or your dependent is disabled, the premium increases to 150% of the group rate after the first 18 months of Cal-COBRA. A person is disabled if he or she meets the Medicare definition of disability. How much will my Cal-COBRA premiums cost me if I get the ARRA premium reduction? If you are eligible for the premium reduction, you will only pay 35% of your Cal-COBRA premium. Your premiums may be reduced for up to 9 months. After 9 months, you will have to pay the full amount. Some dependents are not eligible for premium reduction, even though they are eligible for Cal-COBRA. Domestic partners, same-gender spouses, and grandchildren are not eligible. See the attached “Summary of the Premium Reduction Rules” for more information. Important information about your first premium If you do not pay the correct premium amount within the 45-day deadline you will lose your Cal-COBRA coverage. Your first payment must be delivered to {Name of Health Plan} within 45 days after the date you gave written notice to {Name of Health Plan} that you were electing Cal-COBRA continuation coverage. You must send your first payment by first-class mail, certified mail, or other reliable means of delivery, including personal delivery, express mail, or private courier company. The first payment must cover any and all premiums due. Call {Name of Health Plan} to check the correct amount of your first payment or to ask about the ARRA premium reduction. For more information This notice does not explain all kinds of continuation coverage or your other rights tocoverage. For more information, see your Evidence of Coverage {or} {Certificate of Insurance} {or} {Certificate of Coverage} {or} {Policy} or by contacting {Name of Health Plan}. If you have any questions concerning the information in this notice, your rights to coverage, or your rights under state law, you should contact {Name of Health Plan} at the telephone number noted on your Membership card. Tell your plan if your address changes In order to keep informed and to protect your rights and your family’s rights, you should tell {Name of Health Plan} if there are any changes in your address or the addresses of your family members. Keep copies for your records You should keep a copy of any letters or forms that you send to {Name of Health Plan}. Special Election Period for Cal-COBRA This may be an important opportunity for people who could not afford Cal-COBRA premiums originally, but can afford them with the 65% reduction. If one of the following 3 statements applies to you, please read the rest of this notice carefully: (1) Did you lose group coverage some time between September 1, 2008 and {59 days before the effective date of the state law,} and choose not to elect Cal-COBRA continuation coverage at that time? or (2) Did you elect Cal-COBRA some time between September 1, 2008 and {59 days before the effective date of the state law}, but since then discontinue that coverage? or (2) Did you lose group coverage after {59 days before the effective date of the state law}, but your original Cal-COBRA election period has not yet ended? If you lost health coverage due to an involuntary job loss, you may be eligible for a premium reduction for up to 9 months. You may also be eligible for a second opportunity to elect Cal-COBRA, called a special election period. To find out if you can get the premium reduction and special election period, you should read this notice carefully. Your dependent(s) may also be eligible for the premium reduction and special election period. However, some dependents are not eligible for the premium reduction or the special election period, even though they could elect Cal-COBRA coverage. Domestic partners, same-gender spouses, and grandchildren are not eligible. If you think you are eligible for the special election period and premium reduction, you must complete and return the following 2 forms: “Cal-COBRA Election Form” “Application for Premium Reduction” When Cal-COBRA Coverage Starts If you are eligible for premium reduction and your involuntary termination was before February 17, 2009, your CalCOBRA coverage will start on the first day of the month after you submit the 2 forms listed above. . You must pay all premiums due from that date forward. Your Cal-COBRA coverage will last for up to 36 months from the date of your original qualifying event. The ARRA premium reduction lasts for up to 9 months. If you are eligible for premium reduction and your involuntary job loss was between February 17, 2009 and May 12, 2009, you may choose the date your Cal-COBRA will start. It can start on either (Option 1) the date of your involuntary job loss or (Option 2) the first day of the month following the date you elect Cal-COBRA coverage using the attached forms Option 1: the date of your involuntary job loss (termination). If you choose this option, you must pay for 35% of all premium costs dating back to the date of your involuntary job loss. {Name of Health Plan} will pay all health care costs that would have been covered by Cal-COBRA if you had elected Cal-COBRA at the time of your involuntary job loss. You will not have a “gap in coverage” between the time your coverage under your employer ended and the time you elected Cal-COBRA. If you have no “gap in coverage,” it is easier to get other health care coverage such as HIPAA when your Cal-COBRA coverage ends. Option 2: the first day of the month following the date you elect Cal-COBRA coverage using the attached election forms If you choose this option, you will only pay for 35% of all premiums starting with the month you elect coverage. However, if you choose this option, {Name of Health Plan} will not pay for any of your health care costs that occurred between the date of your involuntary termination and the first day of the month after you elect Cal-COBRA coverage. If you choose this option, you may not be eligible for guaranteed health insurance coverage under HIPAA after your Cal-COBRA expires. If you have questions, please contact {name of health plan} at XXX-XXXXXXX. To apply for the special election period, both of the following forms must be sent to {Name of Health Plan} within 60 days: “Cal-COBRA Election Form” “Application for Premium Reduction” Summary of Premium Reduction Rules Under ARRA President Obama signed the American Recovery and Reinvestment Act (ARRA) on February 17, 2009. This law gives eligible individuals the right to pay reduced premiums for COBRA or Cal-COBRA continuation coverage. The premium is reduced by 65%. Reductions can begin on or after February 17, 2009 and can last up to 9 months. Are You Eligible for Premium Reduction? To receive the premium reduction you must meet all of these 5 requirements: 1. You or your family member must have an involuntary job loss between September 1, 2008 and December 31, 2009. 2. You must be eligible for COBRA or Cal-COBRA continuation coverage due to this job loss. 3. You must enroll in COBRA or Cal-COBRA. 4. You must not be eligible for Medicare. 5. You must not be eligible for any other group health plan, such as a plan offered by a new employer or your spouse’s employer. Alerts: Before You Apply for Premium Reduction You must tell your health plan in writing if you become eligible for another group health plan or Medicare while you are receiving the premium reduction. If you do not notify your plan, you may have to pay a tax penalty. If you receive the premium reduction, you cannot get the Health Coverage Tax Credit. This tax credit could save you more money than the premium reduction. If you are eligible for the tax credit, you will have received a notice from the IRS. If you have a high income, you may not want the premium reduction. If the amount you will earn for the year is more than $125,000 (or $250,000 for married couples filing jointly), all or part of the premium reduction may be “recaptured” in taxes. This means that you would have to pay back some or all of the money you saved. For more information, see your tax preparer or go to the IRS webpage on ARRA at www.irs.gov. For More Information, Call {Name of Health Plan} at 1-xxx–xxx-xxxx For information about continuation coverage call {Name of Health Plan}. For information about premium reduction, call {Name of Health Plan}. To let us know that you are no longer eligible for premium reduction, call {Name of Health Plan}. If you are told that you are not eligible for reduced premiums, you have the right to a review. For more information, go to: www.cms.hhs.gov/COBRAContinuationofCov Or send an e-mail to: NewCobraRights@cms.hhs.gov {Name of Health Plan} Application for Premium Reduction American Recovery and Reinvestment Act of 2009 (ARRA) {Insert Plan Mailing Address} 1. To apply for premium reduction, complete this form and return it to: {Health Plan Name and Address} 2. You can also enclose your “Application to Change Health Plans.” 3. Please read the important information about your rights in the “Summary of the Premium Reduction Rules Under ARRA”. Personal Information for Former Employee/ Main Applicant Name and mailing address of employee (list any dependents on the back of this form): Telephone number: E-mail address (optional): {Name of Health Plan} {Membership Number and/or SSN}: {Name of Health Plan Group Number}: To be eligible, you must be able to check ‘Yes’ for all statements. 1. My loss of employment was involuntary. 2. My loss of employment was on or after September 1, 2008 and on or before December 31, 2009. 3. I elected (or am electing) Cal-COBRA continuation coverage.* Yes Yes Yes No No No 4. I am NOT eligible for another group health plan (or I was not eligible for another group health plan during the period for which I am requesting premium reduction). 5. I am NOT eligible for Medicare (or I was not eligible for Medicare during the period for which I am requesting premium reduction). *If you checked NO for statement 3, you may still be eligible. See below for more information. Yes No Yes No Special Cal-COBRA Election Period You may have the right to another 60-day period when you can elect (enroll in) Cal-COBRA. You must have an involuntary job loss at some time from September 1, 2008 through February 16, 2009. One of the following statements must also be true: You were eligible for, but did not elect, Cal-COBRA coverage, OR You elected but then stopped your Cal-COBRA coverage. For more information, see the “Special Election Period” notice included in this envelope. You MUST complete and return a new “CalCOBRA Continuation Coverage Election Form” along with the “Special Election Form.” I am requesting the ARRA Premium Reduction. To the best of my knowledge and belief, all of my answers on this form are true and correct. Signature: Type or print name: Date: Relationship to employee: Information about Dependents (Parent or guardian should sign for minor children.) Name of dependent: Relationship to Employee: Date of Birth: SSN (or other identifier): 1. I elected (or am electing) Cal-COBRA continuation coverage. 2. I am NOT eligible for another group health plan. 3. I am NOT eligible for Medicare. {4. I am NOT a Domestic Partner of the subscriber.} {5. I am NOT a same-sex spouse of the subscriber.} {6. I am NOT a grandchild of the subscriber.} { { { Yes Yes Yes Yes Yes Yes No No No No} No} No} I am applying for ARRA premium reduction. To the best of my knowledge and belief all of the answers I have provided on this form are true and correct: Signature: Type or print name: Date: Relationship to employee: Name of dependent: Relationship to Employee: 1. I elected (or am electing) Cal-COBRA continuation coverage. 2. I am NOT eligible for another group health plan. 3. I am NOT eligible for Medicare. {4. I am NOT a Domestic Partner of the subscriber.} {5. I am NOT a same-sex spouse of the subscriber.} {6. I am NOT a grandchild of the subscriber.} Date of Birth: SSN (or other identifier): Yes Yes Yes { { { Yes Yes Yes No No No No} No} No} I am applying for the ARRA Premium Reduction. To the best of my knowledge and belief all of the answers I have provided on this form are true and correct: Signature: Type or print name: Date: Relationship to employee: FOR PLAN OR CARRIER USE ONLY This application is: Approved Denied Approved for some/denied for others (explain in #4 below) Specify reason below and then return a copy of this form to the applicant. Reason for Denial of Premium Reduction 1. Loss of employment was voluntary, rather than involuntary. 2. Loss of employment was involuntary, but did not occur between September 1, 2008 and December Yes Yes No No 31, 2009. 3. The applicant did not elect Cal-COBRA continuation coverage. 4. Other (please explain): Yes No Signature of party responsible for continuation coverage administration for the Plan: Date: Type or print name: Telephone number: E-mail address: This form is designed for carriers to distribute to qualified Cal-COBRA beneficiaries who are paying reduced premiums pursuant to ARRA so they can notify the carrier if they become eligible for other group health plan coverage or Medicare. Use this form to notify your health insurance company that you are eligible for another group health plan or Medicare. {Insert Plan Mailing Address} {Name of Health Plan} Notice of Change in Eligibility (Beneficiary is no longer eligible for premium reduction) Personal Information Name and mailing address: Telephone number: E-mail address (optional): Reasons I am no longer eligible for premium reduction – Check one I am eligible for another group health plan. If any dependents are also eligible for other coverage, include their names below, at the end of this form. The date I became eligible: I am eligible for Medicare. The date I became eligible for other coverage: IMPORTANT {Alternative 1: For use where the employer provides the attestation.} {You must tell your health plan if you are eligible for another group health plan or Medicare, even if you do not enroll in the other plan or Medicare. If you do not tell, and you keep getting the premium reduction, you may have to pay back the amount of your premium reductions plus a 10% fine. • If you enroll in another plan, there may be a waiting period before you can get care. You can keep getting premium reduction in your Cal-COBRA plan until the waiting period in your new plan is over.} {Alternative 2: For use where the employee provides the attestation, whether or not it is in a document provided to the employee by the employer.} {You must tell your health plan if you are eligible for another group health plan or Medicare, even if you do not enroll in the other plan or Medicare. If you do not tell, or you give false information about your eligibility, and you keep getting premium reduction, you may have to pay back the amount of your premium reductions plus a 10% fine. • If you enroll in another plan, there may be a waiting period before you can get care. You can keep getting premium reduction in your Cal-COBRA plan until the waiting period in your new plan is over.} To the best of my knowledge and belief all of the answers I have provided on this form are true and correct: Signature: Type or print name: Date: If you are eligible for coverage under another group health plan and that plan covers dependents you must also list their names here: Application to Change Health Plans Send this form to your former employer. If they allow you to change health plans, they must complete the appropriate portions of this form and forward it, and any other necessary information, to the new health plan. PERSONAL INFORMATION Name and mailing address of employee (list any dependents on the back of this form): Telephone number: E-mail address (optional): Social Security Number: Name and mailing address of former employer: Telephone number: E-mail address (optional): Name and Member ID of current health plan: To be eligible to change your health plan, you must be able to check ‘Yes’ for all statements. 1. I am currently enrolled in Cal-COBRA with the health plan named above OR I am electing Cal-COBRA coverage now and changing to a new health plan. 2. My loss of employment was involuntary. 3. My loss of employment occurred on or after September 1, 2008 and on or before December 31, 2009. 4. My former employer allows a change to a different health plan. Yes No Yes Yes Yes No No No I am enrolling in this health plan’s Cal-COBRA continuation coverage as allowed by my employer. To the best of my knowledge and belief all of the answers I have provided on this form are true and correct: Signature: Type or print name: Date: Relationship to employee: FOR EMPLOYER USE ONLY EMPLOYER - COMPLETE THIS SECTION AND SUBMIT TO THE HEALTH PLAN YOU HAVE APPROVED FOR ALTERNATIVE COVERAGE Name and address of alternative plan: Phone number: 1. The applicant was validly enrolled in group health coverage at the time of their qualifying event. 2. The loss of employment was involuntary. 4. The former employer allows a change in coverage to a different health plan. Yes Yes Yes No No No 5. The premiums for new coverage do not exceed the premiums for the enrollee’s original coverage. Signature of the former employer or party authorized to act for the employer: Date: Type or print name: Telephone number: E-mail address: Yes No FOR PLAN OR CARRIER USE ONLY This application is: Approved Denied Approved for some/denied for others (explain in #4 below) Specify reason below and then return a copy of this form to the applicant. REASON FOR DENIAL OF Reduced Premium 1. Loss of employment was voluntary, not involuntary. 2. Loss of employment was involuntary, but did not occur between September 1, 2008 and December 31, 2009. 3. The applicant’s employer does not permit a change in coverage. 4. Other (please explain): Yes Yes Yes No No No Signature of plan, carrier, or other party responsible for administration of the Cal-COBRA coverage: Date: Type or print name: Telephone number: E-mail address: Verification of Involuntary Termination To be completed by Applicant and Former Employer {Health plan attach this form only if you are requesting the qualified beneficiary to submit this form to their former employer} INSTRUCTIONS: Applicant for Premium Reduction: Please submit this form to your former employer. For Employer: Under the new federal American Recovery and Reinvestment Act of 2009, certain people who enroll in CalCOBRA coverage may receive a reduction in premiums for up to 9 months. To be eligible, your former employee must have been involuntarily terminated between September 1, 2008 and December 31, 2009. Please answer the question below to help the carrier determine whether the applicant is eligible under federal law. Pursuant to California Law, the employer must complete and sign this form within 10 calendar days and submit it to: {Name and Address of Health Plan} APPLICANT PLEASE COMPLETE Name applicant: {Social Security Number:} Address of applicant: FOR EMPLOYER USE ONLY This employee’s employment was involuntarily terminated between September 1, 2008 and December 31, 2009. Yes No I certify the above information is true and correct: Signature: Company Name: Date: Telephone: