Form F8026r05 - Cobra & Continuation Election Notice printable pdf download

COBRA & Continuation Election Notice

Instructions: Pages 1-7 to be completed by group and given to the employee.

Page 7 only to be completed by the plan administrator and employee and returned to

BCBSM, P.O. Box 64024, St. Paul, MN 55164 or return it via fax to 1-651-662-2745.

Date:

_____________________________________

Enter Name of Employer:

_____________________________________________________________

Dear:

_________________________________________________________

[Identify the qualified beneficiary(ies), by name]

This notice contains important information about your right to continue your health care coverage in the

plan as well as other health coverage alternatives that may be available to you.

Please read the information contained in this notice very carefully.

To elect COBRA continuation coverage, complete the enclosed Election Form and submit it to us.

If you do not elect COBRA continuation coverage, your coverage under the Plan will end on ________

due to:

(enter date)

End of employment (18 months)

Reduction in hours of employment (18 months)

Active military service (24 months)

Divorce (36 months or indefinite)

Death of employee (36 months or indefinite)

Loss of dependent child status (36 months)

Entitlement to Medicare (36 months total)

Each person (“qualified beneficiary”) in the category(ies) checked below is entitled to elect COBRA

continuation coverage, which will continue group health care coverage under the Plan for up to

__________ months [enter 18, 36, or indefinite as appropriate and check appropriate box or boxes]:

Relationship:

Name:

Employee or former employee

Spouse or former spouse

Dependent child(ren) covered under the Plan on the

day before the event that caused the loss of coverage

Child who is losing coverage under the Plan because

he or she is no longer a dependent under the Plan

If elected, COBRA continuation coverage will begin on ______________ and can last until ___________

[enter date]

You may elect any of the following options for COBRA continuation coverage:

Health

Dental

COBRA continuation coverage will cost:

Health:

Dental:

Single

Family

You do not have to send any payment with the Election Form. Important additional information about

payment for COBRA continuation coverage is included in the pages following the Election Form.

There may be other coverage options for you and your family. When key parts of the health care law take

effect, you’ll be able to buy coverage through the Health Insurance Marketplace. In the Marketplace, you

could be eligible for a new kind of tax credit that lowers your monthly premiums right away, and you can

see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll.

Being eligible for COBRA does not limit your eligibility for coverage for a tax credit through the

Marketplace. Additionally, you may qualify for special enrollment opportunity for another group health

F8026R05 (05/14)

Form F8026r05 - Cobra & Continuation Election Notice

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