Extended Coverage/cobra Change Request Form-Commonwealth Of Virginia Health Benefits Program printable pdf download

Commonwealth of Virginia Health Benefits Program

Extended Coverage/COBRA Change Request

This form should be used by qualified beneficiaries to make allowable changes to an existing Extended Coverage/COBRA plan or membership.

For initial COBRA enrollment, submit the Election Form provided in your Election Notice. Your Election Notice also includes information about

your Extended Coverage/COBRA rights and responsibilities.

PARt A: Identification of the Qualified Beneficiary/Enrollee Submitting the Form

PLEASE PRINT

________________________________________

Name ______________________________________________________________________

Health Plan ID Number

First Name

M.I.

Last Name

______________________________________________________________________________________________________________________

Address

Street

City

State

Zip + 4

Work Phone: ( _______ ) _______________ Home Phone: ( _______ ) _______________

Sex:

Male

Female

Date of Birth _______________________

MM/DD/YYYY

PARt B: Requesting Changes to Membership Level

After initial enrollment, you may make changes to your plan and membership during the annual Open Enrollment (non-Medicare coordinating

plans only) or within 60 days of a qualifying mid-year event. The change must be consistent with the event. These are the same opportunities

available to similarly-situated non-Extended Coverage/COBRA participants. COBRA qualified beneficiaries may end coverage at any time by

stopping premium payment.

Ending Coverage

Since each qualified beneficiary has an independent right to coverage, individuals may end Extended Coverage/COBRA at any time by ceasing

to pay his/her monthly premium (or his/her part of the total premium) by the end of the payment grace period. If you wish to end coverage for

individual members of your family group, please notify the plan by submitting the following information:

Premium payment will be stopped for the following qualified beneficiary/ies

Name/s of affected qualified beneficiary/ies: ___________________________________________________________________________________

If you wish to end coverage for all qualified beneficiaries and dependents in your covered family group, stop paying the total premium. Coverage

will be terminated at the end of the payment grace period.

If coverage is to end for the following reasons, please check the appropriate box, and provide documentation to support the change (this could

affect the date of change). Some changes (*) may require termination of Extended Coverage/COBRA. See your Election Notice for more information.

Name/s of affected qualified beneficiary/ies or dependent/s: _____________________________________________________________________

Death of qualified beneficiary/dependent

Qualified beneficiary/dependent gained entitlement to Medicaid

Judgment, decree or order issued to end a child’s coverage

Qualified beneficiary enrolled in other group health plan coverage*

Qualified beneficiary became entitled to Medicare (A, B or both)*

Qualified beneficiary has ceased to be disabled during the disability extension as determined by the Social Security Administration*

Membership Increases

If you are requesting an increase in membership, please indicate the qualifying event below and attach documentation to support the event.

Name/s of dependent/s to be added: __________________________________________________________________________________________

Marriage**

Other HIPAA Special Enrollment**

Birth or adoption**

__ Dependent loses coverage for which they declined enrollment

Judgment, decree or order issued to add a child

in this plan

Spouse or child lost government-sponsored plan, Medicare or

__ Dependent loses coverage in Medicaid or the State Children’s

Medicaid

Health Insurance Program (CHIP)

Spouse or eligible child lost employer eligibility

__ Dependent becomes eligible for Medicaid or CHIP premium

Qualified beneficiary gained permanent sole custody of a child

assistance subsidy

Open Enrollment (plan and/or membership change)

Other: ____________________________________________________

**HIPAA Special Enrollments allow the addition of all eligible dependents

Second Qualifying Event

The following second qualifying events can result in increased duration of the Extended Coverage/COBRA period. See your Election Notice

for additional information and requirements. You must provide documentation to support these events.

Name/s of affected qualified beneficiary/ies: ___________________________________________________________________________________

Covered child ceased to be eligible under provisions of plan

Divorce from former employee

Determined to be disabled by the Social Security Administration

Death of former employee

T20878 (7/2013)

Extended Coverage/cobra Change Request Form-Commonwealth Of Virginia Health Benefits Program

Related Articles

Related forms

Related Categories