Welcome to CobraServ - Rogers Benefit Group

Transcription

Welcome to CobraServ
Managed business solutions for human resources and employee effectiveness
WELCOME TO CobraServ
Dear CobraServ Customer:
Welcome to CobraServ - the nation’s largest COBRA compliance service. We look forward to providing you with the
best COBRA compliance administration available, to minimize your involvement in COBRA.
Members of our implementation team will be contacting you. They will review the materials in this section
("Welcome to CobraServ") and the section entitled "CobraServ Forms" and discuss how CobraServ can best meet your
needs. Our team will show you just how well they know COBRA – and will share their knowledge with you.
CobraServ does it all, from assuming administration of your COBRA continuants, to performing future billing and
adjudication of eligibility, to collecting and processing all related transactions.
With CobraServ, your role is reduced to responding to 3 situations:
1 When individuals first become covered under your plan;
2 When an individual experiences a COBRA Qualifying Event;
3 If you receive a report of COBRA activity that requires response.
In this document, you will find information concerning:
• What CobraServ Does
• What the Employer Does
• Reports and Updating Your Carrier
• COBRA Compliance Requirements
WHAT CobraServ DOES
Elections, Billing, Reporting, Additional Services
Elections
• CobraServ Customer Service Representatives (CSRs) respond to all inquiries from Qualified Beneficiaries.
• CobraServ provides a toll-free hotline to continuants 24 hours-a-day, 365 days a year for premium inquiries
through our Interactive Voice Response (IVR) system.
• Qualified Beneficiaries can elect COBRA by phone via the IVR system; on our Website using Elect By Net; or
on paper with a COBRA Election Form.
• CobraServ determines whether the elections CobraServ receives were made within the allowable 60-day period.
• CobraServ offers special status reports to employers.
• We provide an employer a toll-free hotline to call for assistance.
Billing
• CobraServ administers the initial 45-day and ongoing 30-day grace periods.
• Each month, CobraServ sends each continuant a detailed bill with a payment envelope and a request for
ongoing certification of continuant eligibility.
• CobraServ sends grace letters to those who don’t pay within eight days of the grace expiration date.
• CobraServ determines any late payments. We accept full and partial premium payments, within “Safe Harbor”.
• Checks are returned that are non-negotiable (no signature, wrong payee, etc.) if they are received by
CobraServ more than 10 days before the grace period expiration date.
• Checks received less than 10 days before the grace period expiration date are also returned, and the COBRA
continuant is given up to 10-days to correct their non-negotiable check.
• CobraServ follows up on dishonored checks.
• CobraServ archives critical documents and materials for seven years in a professional archiving facility, to
resolve potential disputes.
• CobraServ sends cancellation notices to those who do not pay their premiums within the grace period.
• If you have active continuants, you will receive a
monthly consolidated premium check representing premiums collected from COBRA continuants, less the 2% administrative fee paid by
the continuant. Accompanying reports
will indicate actions to be taken, if any.
WHAT CobraServ DOES (continued)
Elections, Billing, Reporting, Additional Services
Additional Services
CobraServ also provides the following additional services:
• employs two different ERISA law firms to help keep your plan in compliance and to stay up-to-date on
court cases affecting COBRA. CobraServ forms are updated as the regulations change;
• utilizes a Research Department to stay current on compliance changes and trends through subscriptions
to industry publications, legislative bulletins and legal update services;
• sends conversion notices, where appropriate, in the last 90 days before COBRA reaches maximum term;
• accepts calls from providers, hospital representatives, agents, brokers or HMOs regarding coverages/
eligibility;
• provides employer with mail labels for all COBRA continuants to assist in Open Enrollment communications;
• handles multiple Qualifying Events (for example, termination of employment followed by divorce);
• provides ongoing customer service to all administrators and continuants.
OVERVIEW OF EMPLOYER RESPONSIBILITIES
Initial Notice of COBRA Rights
Whenever a new employee or a spouse or a dependent child first becomes covered under the group health plan,
he and/or she must be provided an Initial Notification of COBRA Rights. A sample Initial Notice of COBRA Rights
is included in your COBRA Compliance Implementation Kit.
New Qualifying Events
Any of the following events that would cause an employee, spouse or dependent to lose coverage under the
group health plan is considered a COBRA Qualifying Event:
• Termination of the employee’s employment for any reason other than gross misconduct (layoff, resignation,
retirement, etc.)
• Employee’s reduction of hours
• Death of the covered employee
• Divorce or legal separation from the covered employee
• Dependent child of the covered employee ceasing to meet eligibility requirements under the Group Health Plan
• Covered employee/retiree becomes entitled to Medicare
• Retiree or retiree’s spouse or child loses coverage within one (1) year before or after the commencement of
proceedings of the sponsoring employer under Title II (bankruptcy), United States Code.
An individual who loses coverage under the group health plan because of a Qualifying Event is a Qualified
Beneficiary.
1. When a Qualifying Event causes an employee or a dependent to lose coverage under the group health plan,
you must mail a COBRA Notification Form to the Qualified Beneficiary within fourteen (14) days of the
Qualifying Event; even if the Qualified Beneficiary tells you he or she does not want continuation coverage.
The Department of Labor has indicated the best method of delivery to the Qualified Beneficiary is by properly addressed First-Class Mail.
2. Remove the top page of the COBRA Notification and Election Booklet. Complete the COBRA Notification
Form as indicated on the first page of the booklet, "Employer Instructions" and on the "Sample Form" page of
the booklet.
3. Remove the blue-bordered and pink-bordered copies of the COBRA Notification Form from the booklet.
Within fourteen (14) days of the Qualifying Event, mail all remaining pages via First- Class Mail, together
with a copy of the COBRA Rate Sheet, to the Qualified Beneficiary and spouse by name, and eligible dependents, if covered under the group health plan to their last- known home address (i.e., John Smith and Mary
Smith and Eligible Dependents).
4. Mail the blue bordered COBRA Notification Form to CobraServ within 14 days of the Qualifying Event.
Please, DO NOT FAX the form to us.
5. Retain the pink-bordered "Employer Copy" of the form for your records.
6. Terminate this person from your group insurance plan, effective as of the "Benefits Termination Date."
If you have any questions regarding the Initial Notice or if you need assistance in completing the COBRA
Notification Form, please call CobraServ Client Services at 800/488-8757. We also have a separate toll-free dedicated COBRA continuant line, 800/877-7994.
WHAT TO DO WITH REPORTS
Participant Update, Monthly Participant Status,
Premium Distribution Reports
Reports / Carrier Updating
CobraServ will send you reports of:
• COBRA continuants electing COBRA and paying the first premium;
• dependents being added or dropped;
• continuants being cancelled.
Your role is to review these reports, and report the addition, termination or dependent change to the
appropriate carrier(s).
Description of the Reports
• Participant Update Reports are generated by CobraServ and sent to the employer providing detail of continuants who make the initial COBRA premium payment, cancellations, or change of their dependents’ status.
These reports are sent on a daily or weekly basis and provide you with the information needed to update
your carrier.
• Once a month, the employer receives the Monthly Participant Status Report from CobraServ and a
Premium Distribution Report summarizing all activity for the previous month and a consolidated check for
the premiums collected, less the 2% administrative fee paid by the continuant.
The next three pages will provide you some sample reports.
PARTICIPANT UPDATE REPORT SAMPLE REPORT
(Provided immediately upon election with payment, cancellation,
reinstatement or addition/deletion of dependents)
PARTICIPANT STATUS SAMPLE REPORT
(Provided monthly)
PREMIUM DISTRIBUTION SAMPLE REPORT
(Provided monthly)
SAMPLE MONTHLY PREMIUM REIMBURSEMENT
COBRA COMPLIANCE REQUIREMENTS
Who has to Comply?
Every employer (except "church groups") who
maintains a group health insurance plan, and
who employs 20 or more full- and/or part-time
employees during 50% of the business days in
the preceding calendar year or as further defined under the 2001 Final COBRA Regulations.
Notification of Rights
1. The employer or the plan administrator
must notify every employee and every covered spouse of all of their rights under
COBRA within 90 days of becoming covered under the group health plan. Separate
notices must be sent if separate residences
are maintained. This applies to all current
and future employees and covered spouses.
2. Each time a Qualifying Event occurs, the employer must, within 14 days of notification
to the Plan Administrator, notify each
Qualified Beneficiary of his/her continuation rights, benefits and premium rates for
the plan(s) in which they're eligible.
For either kind of notification, good faith
compliance has been defined as First-Class
Mail, addressed to both the employee and
spouse and sent to the last known home
address. If covered dependents live at a separate address, separate notifications must be
sent.
Election Rights
When a Qualifying Event causes loss of coverage, the employer must allow continued coverage under the group health plan for up to 18
months in the case of termination of employment or reduction in hours, or up to 36
months for a dependent Qualifying Event. A
second Qualifying Event for a dependent
occurring during the 18-month coverage period of the first Qualifying Event expands the
original period to 36 months.
What is a Qualifying Event?
Any of the following events causing a loss of
coverage by a Qualified Beneficiary under the
plan:
1. Termination (other than for gross misconduct) of the employee's employment, for
any reason (layoff, resignation, retirement,
etc.);
2. Reduction of hours worked by employee;
3. Death of the employee;
4. Divorce or legal separation;
5. Dependent child ceasing to meet eligibility
requirements;
6. Dependent coverage is lost because the
active employee (or COBRA continuant)
becomes entitled to Medicare.
right applies to similarly situated active
employees.
7. Retiree or retiree's spouse or child loses
coverage within one year before or after the
commencement of proceedings under Title
11 (bankruptcy), United States Code of the
sponsoring employer.
Ongoing Administration
Who is a Qualified Beneficiary?
Any employee, spouse or dependent child
who was covered on the day before the
Qualifying Event and who would otherwise
lose coverage under the plan because of the
Qualifying Event. This definition also includes
a child born to or placed for adoption with a
covered employee during the period of
COBRA coverage.
Election Timeframe
Qualified Beneficiaries are allowed to buy continuation coverage retroactive to the benefit
termination date. They are entitled to make
this election within 60 days of the date of the
notification of their rights or the date that
benefits would terminate, whichever is later. If
they decline, they may change their minds
and elect — if they are still within the 60-day
election period.
Choices of Coverage
Each Qualified Beneficiary must be allowed to
make an independent election. For example, if
the plan contains medical and dental coverage, the employee may decline coverage, the
spouse may elect medical only, and the child
may elect medical and dental.
Dependents
You must allow 'branching" of coverage. If a
continuant elects family coverage, his or her
dependent(s) are allowed to continue benefits
if/when they would otherwise cease to be eligible under the contract as dependents during
the 18- 36-month continuation period.
Qualified Beneficiaries other than the covered
employee may continue coverage for up to 36
months from the date of the covered employee's Medicare entitlement, if the covered
employee becomes entitled to Medicare and,
within 18 months thereafter, has a Qualifying
Event.
You must allow continuants to add dependents if the dependents meet the special enrollment rules under the Health Insurance
Portability and Accountability Act (HIPAA) or
if the continuants acquire any new dependents after their Qualifying Event — if such a
You must allow continuants to change benefits annually if the option is available to active
employees (i.e., flexible benefits plans/HMO
dual option plans). Open Enrollment periods
must be allowed for continuants on the same
basis as for active employees. Continuants
must be offered a conversion privilege at the
end of the 18- or 36-month period, if one is
available to active employees.
You must allow existing COBRA continuants
to continue coverage as long as they meet the
eligibility requirements, even if your group
size fails below 20 full-time andlor part-time
employees.
Payments
The employer or plan administrator must
allow continuants to pay their first premium
within 45 days of the date they elect coverage,
if coverage is elected within the 60-day election period. You may not require any premium payment until 45 days from the date of
election. You must allow a grace period of not
less than 30 days for the payment of all subsequent premiums.
Disability Extension
A Qualified Beneficiary's (and that of any
other covered members of the family) continuation period must be extended to 29 months
from 18 months if the Social Security Administration determines that the Qualified Beneficiary
was totally disabled under Title 11 or XVI of
the Social Security Act on the day of the Qualifying Event, or within the first 60 days of COBRA
coverage, and the Qualified Beneficiary sends
a copy of the determination notice to CobraServ before the end of the initial 18-month
period and within 60 days of the date of the
notice from the SSA.
Other Coverages
You must allow continuant(s) to continue
COBRA coverage despite their becoming covered under a new group health plan if the new
plan contains an exclusion or limitation with
respect to any pre-existing condition of that
continuant.
See Your Attorney
The complexity of the law — and the fact that
judicial decisions affecting compliance can
happen at any time — precludes a complete
description of legal requirements. Please consult your attorney.
Learn more online at www.ceridian.com/myceridian
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*VERY IMPORTANT NOTICE*
INITIAL NOTICE OF COBRA RIGHTS
EMPLOYER
(employer completes both address sections)
FROM:
Contact Person/Department:
NAME
PHONE
DATE:
TO:
NAME
ADDRESS
CITY/ST/ZIP
A federal law known as COBRA (Consolidated Omnibus Budget
Reconciliation Act of 1985 as amended) requires most employers sponsoring group health plans to notify all of their employees, including newlyhired, current and previous employees (and their dependents) of their
rights to “continuation” health care coverage in the event they would lose
coverage due to certain events called “Qualifying Events.” This notice is the
employer’s fulfillment of this obligation. If you, your spouse or dependent
child(ren) are or become participants in the above employer’s group health
plan(s), it is important to understand your ongoing rights and obligations
under the continuation of coverage provisions of COBRA. This summary of
rights should be reviewed by both you and your spouse (if applicable),
retained with other benefits documents, and referred to in the event that any
action is required on your part.
If you, your spouse or dependent child(ren) should lose coverage
under the above employer’s group health plan(s) due to a “Qualifying
Event” (listed below), you may be entitled to elect temporary continuation
of health care coverage (“continuation coverage”) at group rates. It is
important that your sponsoring employer have your current address.
Notification of a Qualifying Event should one occur, will be sent to your last
known address at the time of the event. The following summary of
information concerning COBRA outlines the procedures which should be
followed if or when a Qualifying Event occurs.
If you are an employee of the employer designated in the “EMPLOYER” box above and are covered by its group health plan, you have
a right to elect continuation coverage if you lose your group health coverage
because of a reduction in your hours of employment or the termination of
your employment (for reasons other than gross misconduct).
If you are the covered spouse of the above covered employee, you
have the right to elect continuation coverage for yourself if you lose group
health coverage for any of the following reasons:
(1) The death of your spouse;
(2) The termination of your spouse’s employment (for reasons
other than gross misconduct) or reduction in your spouse’s
hours of employment;
(3) Divorce or legal separation from your spouse; or
(4) Your spouse becomes entitled to Medicare.
If you are a covered dependent child of the above employee, you
have the right to elect continuation coverage if you lose group health
coverage for any of the following reasons:
(1) The death of the employee;
(2) The termination of the employee’s employment (for reasons
RETAIN THIS NOTICE WITH
YOUR INSURANCE PAPERS
other than gross misconduct) or a reduction in the
employee’s hours of employment;
(3) Parents' divorce or legal separation;
(4) Employee becomes entitled to Medicare; or
(5) The dependent ceases to be a “dependent child” under the
terms of the plan(s).
You also have a right to elect continuation coverage if you are
covered under the plan as a retiree or spouse or child of a retiree, and lose
coverage within one year before or after the commencement of proceedings under Title 11 (bankruptcy), United States Code.
Under the law, the employee (or a covered dependent) has the
responsibility to inform the above named employer of a divorce, legal
separation, or a child losing dependent status under the plan if any of
these events would cause a loss of coverage. This notification must
be made within 60 days after the date of the Qualifying Event, or the
date on which coverage would end under the plan because of the
event, whichever is later. The notice must be in writing, and should be
sent to the contact person or department of the employer indicated on
this form. If notice is not timely made, rights to continue coverage will
terminate. In situations where a covered employee discontinues
coverage of a spouse in anticipation of a divorce or legal separation,
your sponsoring employer, who received timely notification, is required to make COBRA continuation coverage available effective
from the date of the divorce or legal separation (but not prior to that
date). If you need help acting on behalf of an incompetent beneficiary,
please contact the employer indicated for assistance.
When the employer is notified that a Qualifying Event has happened,
it will in turn notify you that you have the right to elect continuation
coverage. Under the law, you have 60 days from the date you would lose
coverage because of one of the events described above, or 60 days from
the date of the employer’s notice of your right to elect continuation
coverage (whichever is later) to elect continuation coverage. If you make
a timely election, coverage will become effective on the day after coverage
would otherwise be terminated. Note: Some states offer financial aid to
help certain individuals pay for COBRA coverage. Contact your
appropriate state agency regarding availability and eligibility requirements. Additionally, under certain circumstances, COBRA coverage may be paid with pre-tax dollars from a cafeteria plan under
Section 125.
If you do not timely elect continuation coverage, your group health
insurance coverage will terminate in accordance with the provisions
outlined in your employer’s plan.
If you elect continuation coverage, your coverage will be identical to
the coverage provided under the plan to similarly situated employees and
their family members. The law requires that you be afforded the opportunity to maintain continuation coverage for 36 months from the date of the
Qualifying Event, unless coverage was lost because of a termination of
employment or a reduction in hours. In that case, the required continuation
coverage period is 18 months measured from the Qualifying Event date.
The 18-month period may be extended to 29 months for disabled Qualified
Beneficiaries under certain circumstances, as described on the reverse
side of this notice.
However, the law also provides that continuation coverage may end
prior to the expiration of the 18-, 29- or 36-month period described above
if any one of the following occurs:
• The Qualified Beneficiary fails to pay the required premium in a
timely manner;
• The Qualified Beneficiary first becomes, after the date of election,
Continued on next page
CS-306/2/02SAL
ORIGINAL—EMPLOYEE
COPY—EMPLOYER
© 2002 Ceridian Corporation
INITIAL NOTICE OF COBRA RIGHTS (continued)
entitled to Medicare;
• The employer/former employer no longer provides group health
coverage to any of its employees;
• The Qualified Beneficiary first becomes, after the date of election,
covered under another group health plan (as an employee or
otherwise) which does not contain any exclusion or limitation with
respect to any preexisting condition of the Qualified Beneficiary.
You do not have to show that you are insurable to choose continuation
coverage. However, continuation coverage under COBRA is provided
subject to your eligibility for coverage under the plan. The employer
reserves the right to terminate your continuation coverage retroactively if
you are determined to be ineligible.
Under the law, you may have to pay all or part of the premium for your
continuation coverage. Your employer may charge you up to 102% of the
applicable premium for your continuation coverage. The law also says that,
at the end of the 18-month, 29-month or 36-month continuation coverage
period, you must be allowed to enroll in an individual conversion health
plan if one is provided under the terms of the employer’s group health
plan. In addition, under the Health Insurance Portability & Accountability
Act (HIPAA, 1996), in certain circumstances, such as when you exhaust
COBRA coverage, you may have the right to buy individual health coverage
with no pre-existing condition exclusion without having to give evidence of
good health.
Once your continuation coverage terminates for any reason, it cannot
be reinstated.
Please notify the contact person or department indicated in the
EMPLOYER box on the front side of this notice if:
• you have any questions about this material;
• you have a change in marital status, or you, your spouse, or
eligible covered dependent has a change of address.
Also, if your spouse or any covered child resides at a different address,
please notify the employer in writing, so that a separate notice may be sent.
COBRA Questions and Answers
A) Who is a Qualified Beneficiary?
A Qualified Beneficiary is any employee, former employee, or spouse or
dependent child of an employee or former employee, who was covered
under the employer’s group health plan on the day before the Qualifying
Event. The definition also includes a child born to or placed for adoption with
a covered employee during the period of COBRA coverage.
B) What is a Qualifying Event?
A Qualifying Event is any of the following events which would cause an
employee, former employee, covered spouse or covered dependent child
to lose coverage under the employer’s group health plan. These events
include:
a) with respect to a Qualified Beneficiary, an employee’s termination
of employment (includes voluntary resignation and involuntary
termination, except when termination is due to gross misconduct),
retirement, or layoff;
b) with respect to a Qualified Beneficiary, an employee’s reduction of
work hours (includes work stoppage, strike, or employee begins
leave of absence);
c) with respect to a Qualified Beneficiary other than the employee,
death of a covered employee;
d) with respect to a Qualified Beneficiary other than the employee,
divorce or legal separation from a covered employee;
e) with respect to a Qualified Beneficiary other than the employee, a
CS-306/2/02SAL
ORIGINAL—EMPLOYEE
dependent child’s loss of eligibility due to the plan’s eligibility
definitions;
f) with respect to a Qualified Beneficiary other than the employee,
an employee becoming entitled to Medicare.
g) with respect to a retiree or spouse or child of a retiree, loss of
coverage within one year before or after the sponsoring
employer’s commencement of proceedings under Title 11
(bankruptcy), United States Code.
C) How long may coverage be continued?
If the Qualifying Event is either “(a)” or “(b)” in question B above, coverage
may be continued for up to 18 months,* which is measured from the date
of the Qualifying Event. For Qualified Beneficiaries other than the covered
employee, coverage may be continued for: (i) up to 36 months from any
other Qualifying Event, which is measured from the date of the original
Qualifying Event, or, (ii) up to 36 months measured from the date of the
covered employee's Medicare entitlement, if the covered employee becomes entitled to Medicare and, within 18 months thereafter, has a
Qualifying Event (either "(a)" or "(b)" in question B above). However,
continuation coverage may end prior to the expiration of the 18-, 29- or
36-month period, as described on the reverse side of this notice.
*Note: A Qualified Beneficiary who is determined under Title II or
XVI of the Social Security Act, to have been disabled at the time of
a Qualifying Event or within the first 60 days of COBRA coverage
described in “(a)” or “(b)” in question B above may be eligible to
continue coverage for an additional 11 months (29 months total).
In order to obtain this extension of coverage, the Qualified Beneficiary must provide the employer with the written determination of
disability from the Social Security Administration within 60 days of
the date of the determination of disability by the Social Security
Administration and prior to the end of the 18-month continuation
period. The employer can charge up to 150% of the applicable
premium during the 11-month disability extension. If coverage is
extended to 29 months, coverage will cease upon a final determination that the Qualified Beneficiary is no longer disabled. The
disabled individual must notify the Employer within 30 days of any
final determination that he or she is no longer disabled.
D) What coverage(s) may be continued?
Qualified Beneficiaries may continue only those group health coverages
that were in effect on the day before the Qualifying Event.
E) Can Qualified Beneficiaries make separate coverage elections?
Yes, Qualified Beneficiaries may make separate elections. Each Qualified
Beneficiary may choose any benefit coverage for which he or she is
eligible. If Qualified Beneficiaries wish to make independent elections,
they must complete separate election forms. Parents or guardians may
elect coverage on behalf of minor dependent children.
F) How much will it cost me to continue coverage under COBRA?
The cost to continue coverage is the applicable group premium rate for
coverage elected, plus an administration fee, if applicable. Premium rates
(including administration fees where applicable) should be provided to you
at the time of a Qualifying Event. These rates are subject to change.
G) When does COBRA coverage begin?
COBRA continuation coverage begins on the day after the date that
coverage would otherwise terminate under the plan, only if the election
form is sent within the allotted time period and all other eligibility requirements are satisfied.
COPY—EMPLOYER
COBRA Continuant Takeover Form
CS-614/6/00CAP
(For transferring current COBRA continuants to CobraServ)
PLEASE CHECK
ONE BOX ➥
❑
❑
ORIGINAL NOTICE If FAXED, do not mail copy.
REVISION . . . to a form that was previously sent.
INSTRUCTIONS: Please type or print, IN BLACK OR BLUE INK, clearly.
• Fill out just one form per family unit (Qualified Beneficiary and dependents).
• Use this form to report existing COBRA continuants who will be transferred
to CobraServ.
• Please do not use this form to report new Qualifying Events. Use the Qualifying
Event Notification Form.
COMPLETE THIS FORM AND RETURN IT TO:
CobraServ National Service Center, P.O. Box 534066, St. Petersburg, FL 33747-4066
Telephone: 800/488-8757 • Fax: 727/865-3648
1a) FROM: (COMPANY)
1b) Plan Code (Division Code)
Company Code (Unit Code)
□□
□□
14) First premium due-date for which CobraServ is to begin billing.
□□□□□□□□
M
M
D
D
Y
Y
Y
Y
15) COBRA Qualifying Event that caused loss of coverage (check one)
Continuation of coverage for 18 months:
❑ Employee’s termination of employment (Code 1)
(includes voluntary resignation, involuntary termination (except when due to gross
misconduct), retirement, layoff, or leave of absence)
❑ Employee’s reduction in work hours (includes work stoppage or strike) (Code 2)
Continuation of coverage for 36 months:
❑ Death of covered employee /retiree (Code 3) ❑ Ineligibility of dependent child (Code 6)
❑ Divorce/legal separation (Code 4)
❑ Retiree, spouse or child of retiree loses
❑ Covered employee/retiree becomes
coverage within one year before or after
entitled to Medicare; dependents
commencement of proceedings
under Title 11 (bankruptcy) United
may elect continuance of identical
States Code (Code 7)
coverage (Code 5)
16) If employee, does he/she have a health care Flexible Spending Account (FSA)?
(If applicable, refer to the Client Rate Report for the one character or two
characters required [alpha and/or numeric] to complete above.)
❑ (N)o ❑ (Y)es If Yes, MONTHLY contribution $___________________
2) CobraServ Account # (indicated on the Client Rate report for location or subsidiary)
17) Benefits Class (Refer to Client Rate Report for Code)
3) Please be advised that the following is currently on COBRA continuation.
18) Check the current plan code coverages. CobraServ administers only plan
code coverage options that are permitted by your plan or carrier.
❑ (E)mployee
(Check one box only.)
❑ (D)ependent
(Check one box only.)
❑ 1 = Individual
❑ 2 = Individual + 1
❑ 3 = Family
4) Social Security Number of Qualified Beneficiary
—
—
□□□□□□□□□□□
5a) Name of COBRA continuant (last, first, mi)
❑ 9 = Individual + Spouse
❑ 14 = Individual + Child
❑ 15 = Individual + Children
19) Has the continuant been approved for an additional 11-month disability
extension?
❑ (N)o ❑ (Y)es
5b) Street (include apartment number)
20) If the COBRA continuant has dependents covered, please complete the
following. If names are not available, please indicate “N/A.”
5c) City
Dependent Name (first, last, mi)
5d) State
Date of Birth (month/day/year)
5e) Zip Code
❑ (M)ale
Gender(check one)
Social Security Number
6) Home Phone # (if available)
—
—
□□□□□□□□□□□□
❑ (F)emale
—
—
Qualified Beneficiary ❑
Relationship to employee
7) Employee Number (if applicable)
8) Date of Birth
□□□□□□□□
M
M
D
D
Y
Y
Y
Y
9) Gender (check one)
❑ (M)ale
10) Marital Status (Check one box only.)
❑ (S)ingle
❑ (M)arried
❑ (W)idowed
❑ (F)emale
❑ (D)ivorced
□□□□□□□□□□□
—
—
Dependent’s Relationship to Employee ___________________________
12) Qualifying Event Date
□□□□□□□□
M
M
D
D
Y
Y
Y
□□□□□□□□
M
D
D
Y
Y
Y
Y
❑ (F)emale
—
—
❑ (M)ale
Gender (check one)
❑ (F)emale
—
—
Prepared By:
Name: (Print) ________________________________________________
Date:
Y
13) Last day of pre-COBRA Coverage (cannot be prior to Qualifying Event Date)
M
11) If the above individual in box #5 is a dependent of an employee/former
employee, please complete the following:
Employee Name (last, first, mi) _______________________________________
Employee SSN
❑ (M)ale
Gender check one)
□□□□□□□□
M
M
D
D
Y
Y
Y
Y
—
□□□□□□□□□□□□
—
—
□□□□□□□□□□□□
—
Phone #:
Fax #:
CobraServ National Service Center • 3201 34th Street South • St. Petersburg, Florida 33711-3828 • 800/488-8757 • Fax: 727/865-3648
TRANSFERRING CURRENT COBRA CONTINUANTS TO COBRASERV
INSTRUCTIONS FOR COMPLETING
COBRASERV CONTINUANT TAKEOVER FORM (ON REVERSE SIDE)
(USE ONE FORM PER FAMILY UNIT)
This form is only needed if you have current COBRA Continuants to be transferred to
CobraServ. One form should be completed for each family unit and sent to:
CobraServ National Service Center, P.O. Box 534066, St. Petersburg, FL 33747-4066
Number 1:
Enter your company name. If we have
set up your account to report by
division or unit, enter division or region
code and company ID or unit code.
Number 2:
Enter your company’s CobraServ
Account Number.
Number 3:
Check appropriate box to indicate
whether Continuant is an employee or
dependent. (Check one box only.)
Number 4:
Enter the Continuant’s complete ninedigit Social Security Number.
Number 5:
Enter Continuant’s complete name
(last, first, middle initial) and complete
mailing address (street, city, state and
Zip Code).
Number 6:
Enter Continuant’s home phone
number, including area code, if
available.
Number 7:
If the Continuant is an employee who has
an employee ID number, enter it here.
Number 8:
Continuant’s date of birth.
(month, day, year).
Number 9:
Check appropriate box to indicate the
Continuant’s Gender (Male or Female).
Number 10:
Check appropriate box to indicate
marital status of Continuant.
Number 11:
If the Continuant is a dependent of an
employee or former employee, enter
employee’s complete name (last,
first, middle initial), employee’s ninedigit Social Security Number, and
Continuant’s relationship to employee.
Number 12:
Number 13:
Enter the LAST DAY (month, day, year) of
the Continuant’s pre-COBRA coverage.
Number 14:
Enter the FIRST PREMIUM DUE DATE for
which CobraServ is to begin billing.
Number 15:
Check appropriate box (check one
box only) to indicate the type of
Qualifying Event. “Employee’s termination
of employment” includes voluntary
resignation, involuntary termination
(except for termination due to gross
misconduct), retirement, layoff, or leave of
absence.“ Employee’s reduction in
hours” includes work stoppage (strike).
Number 16:
If the employee has a health care
Flexible Spending Account (FSA), check
“Yes” and indicate his or her monthly
contribution.
Number 17:
Refer to your COBRA Rate Sheet and
enter the CobraServ Benefits Class
indicating the coverage in effect for
this individual.
Number 18:
Indicate coverage by checking the box
of the appropriate plan code. Your
carrier may not use some of the choices
indicated: check the choice that
corresponds to the status assigned this
individual by your carrier.
Number 19:
Check appropriate box (Yes or No) to
indicate whether the Continuant has
been approved for an 11-month
disability extension.
Number 20:
Provide information if the Continuant
has dependents covered, and indicate
whether the individual is a Qualified
Beneficiary and was covered under the
group health plan at the time of the original
Qualifying Event or was born to or placed
for adoption with a covered employee
during the period of COBRA coverage.
Enter the month, day and year of the
Qualifying Event.
PLEASE BE SURE TO COMPLETE ALL ITEMS AND TO SIGN AND DATE FORM.
INCOMPLETE FORMS WILL BE RETURNED FOR COMPLETION.
CS-614/6/00CAP
CobraServ National Service Center
St. Petersburg, Florida 33711-3828
800/488-8757 • Fax: 727/865-3648
COBRA PROCEDURES MANUAL
Outlining the policies and procedures followed by our organization
in the fulfillment of COBRA requirements.
This document is supplied solely for the purpose of assisting you in organizing documentation of
your internal COBRA administration practices. To the extent that any of the information contained in
this document is inconsistent with IRS requirements, IRS requirements will govern in all cases.
We suggest that you have this document reviewed by your accountant and/or attorney.
OUR COBRA ADMINISTRATION PROCEDURES:
OUR COBRA ADMINISTRATION SYSTEM:
COBRA administration functions are performed jointly by our organization and
CobraServ, a national COBRA compliance administrator.
(Within our organization, COBRA functions are handled
by:________________________
Our CobraServ contact is:
Client Services Department
CobraServ National Service Center
St. Petersburg, Florida 33711-3828
Phone: 800/488-8757
CobraServ will provide all documentation related to the administrative functions it has
performed on our behalf if requested in connection with an IRS audit.
OUR PROCEDURES — Initial Notification of COBRA Rights (check box(es) that apply):
(Internal person responsible:
_________________________________________)
Each time an employee and/or spouse becomes covered under our plan, they are notified
of their COBRA rights as follows:
CobraServ sends an Initial Notice of COBRA Rights Form, based upon the
Department of Labor Model Notice, via First Class Mail with proof of mailing
addressed to the employee and spouse at the last known home address. If
spouse resides at a different address, notices are sent to both addresses. Proof
of mailing is archived for 7 years.
We send a copy of CobraServ-provided Initial Notice of COBRA Rights Form
#CS-306 via First Class Mail addressed to the employee and spouse at the last
known home address. If spouse resides at a different address, notices are sent
to both addresses. We retain a copy of this form, which includes addressee
information and date sent, on file for 7 years for our records.
We send a reproduction of the Initial Notice of COBRA Rights Form, based upon
the Department of Labor Model Notice, via First Class Mail addressed to the
employee and spouse at the last known home address. If spouse resides at a
different address, notices are sent to both addresses. We retain copies of these
notices for _____ years, and store them
__________________________(location).
All of our currently-covered employees and spouses have been properly provided
with an Initial Notice of COBRA Rights. We retain copies of these notices for
_____ years, and store them __________________________(location).
OUR PROCEDURES — COBRA Qualifying Event Notifications:
_________________________________________)
Each time an employee or dependent has a “Qualifying Event,” we perform the following
procedures:
1. Remove the top page entitled “Employer Instructions.”
2. Fill out COBRA Notification page of the of multi-part COBRA Notification/Election
booklet #CS-205C.
3. Address it to both employee and spouse, if spouse is covered, at their last
known home address (form is designed for a standard window envelope).
4. Enclose a copy of the COBRA Rate Sheet applicable to the recipient.
5. Retain the pink banded copy of the form for our files, and send the blue banded
copy to CobraServ (which they retain in archive for seven years).
6. Mail the Notification/Election booklet via First Class Mail within 14 days of the
Qualifying Event and retain proof of mailing.
7. Terminate the person from our group insurance plan.
CobraServ handles all subsequent administration related to the Qualifying Event.
OUR PROCEDURES — Billing/Collecting/Ongoing Eligibility Adjudication:
_________________________________________)
1. CobraServ handles receipt, adjudication and processing of COBRA elections,
and also handles all of our COBRA premium billing and collecting.
2. CobraServ sends us a Participant Status Update report each time a COBRA
continuant elects and pays the first premium, a dependent is added or dropped,
or a continuant is cancelled.
3. We use this report to update our carrier on COBRA continuants.
4. Once a month, CobraServ sends us a complete summary of our COBRA activity
for the previous month, together with a check for the premiums collected.
5. We check this report against our own records to verify that all proper COBRA
administrative activities have taken place. We also forward premium payments
directly to the applicable insurance carrier.
OUR PROCEDURES — Maintaining copies of standard form letters sent to
Qualified Beneficiaries regarding continuation coverage.
(Forms specified by the IRS as required for audit purposes should be attached to
this document. NOTE: Forms used by CobraServ for such communications during
the period in which CobraServ services were in effect will be provided by
CobraServ when requested at the time of audit.)
_________________________________________)
FORMS ATTACHED (check applicable items):
Forms used prior to utilization of CobraServ administration services.
Non-CobraServ forms currently in use.
Current version of CobraServ forms have been requested (at time of audit only).
OUR INTERNAL AUDIT PROCEDURES RELATED TO COBRA:
Following are the audit procedures we use to ensure that all aspects of COBRA
compliance are being properly administered. (Auditing of CobraServ-performed
functions is accomplished by reconciling our internal COBRA records with reports
provided by CobraServ as COBRA-related activities occur, and monthly summary
reports.)
Listed below are the COBRA administration functions, the person responsible for
auditing them, the audit method, and the audit timeframe.
Function
Sending of Initial Notices to
newly-covered
employees and spouses
Qualifying Event Discovery
Sending of Qualifying Event Notices
with Rate Sheets
Reconciling internal records of
COBRA activities with reports provided
by CobraServ
Adding or deleting persons to/from
the group health plan in response to
COBRA status communicated
by CobraServ
Audited by
Audit Method & Frequency
COPIES OF ALL GROUP HEALTH PLANS:
Accompanying this document are copies of all group health plans in force for
our organization. (Check this box as complete after you have attached copies of all
of your group health plans, to include policy, Summary Plan Description, and all
amendments and riders.)
DETAILS PERTAINING TO ANY PAST REQUEST FOR CONTINUED COVERAGE AND/OR
PENDING LAWSUITS RELATING TO COBRA COVERAGE:
Accompanying this document are records of past requests for continued
coverage and details of pending lawsuits (including pleadings, complaints,
answers, etc.) relating to COBRA coverage. (NOTE: CobraServ keeps copies
of all request letters and correspondence related to requests for continued
coverage, and will make them available upon request at the time of audit.)
(Check this box as complete after you have attached copies of all items requested.)
MAINTENANCE OF RECORDS:
Accompanying this document is information concerning all employees who
have left our employment during the current and 6 preceding tax years. If we
cover any independent contractors under our group health plans, a similar
list for them is provided.*
(Check this box as complete after you have attached the lists requested.)
Information to include:
a) Name
b) Address
c) Marital Status
d) Health plan selected, and whether such plan covered the family or just
the employee.
e) Dental plan selected, and whether such plan covered the family or just
the employee.
f)
Date of termination from the company.
g) Date that COBRA Continuation Coverage was made available to the
terminated employee.
h) Date that COBRA Continuation Coverage was made available to the spouse
and/or dependents of the terminated employee.
i)
With regard to items (g) and (h), was this notice written or oral?
j)
With regard to items (g) and (h), was a separate notice given to each party?
k) With regard to items (g) and (h), was the notice hand delivered or mailed?
l)
Was COBRA Continuation Coverage accepted or rejected by the employee
and/or spouse.
m) Was the termination of the employee voluntary or involuntary?
*NOTE:
The Pink banded copies of form CS-205C provide the majority of information required.
CS-802/8/02 CAP
© 2002 Ceridian

Welcome to CobraServ - Rogers Benefit Group

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