Cal Cobra Cobra And Medicare Survey - Anthem printable pdf download

Cal-COBRA, COBRA and Medicare Survey

In order to ensure compliance with state and federal laws, we need you to update Anthem Blue Cross annually with your company’s

Cal-COBRA or COBRA and Medicare eligibility. Eligibility is determined by the number of employees in your group. Failure to

supply updated information may result in incorrect payments for your employees’ claims and may raise issues for your group

under certain applicable federal laws.

Group No:

______________________________

Please complete this form and mail to the following address:

Group Name: ______________________________

Anthem Blue Cross

PO Box 9062

Address:

_______________________________

Oxnard, CA 93031-9062

City, State, Zip: _____________________________

Federal Tax ID No: __________________________

Or fax to:

(805) 499-0842 or (877) 363-9133

Cal-COBRA, COBRA and Medicare Eligibility

Please provide the following information for the specified calendar year. Below is a worksheet to assist in determining your

employee count. Include all employees, regardless of their enrollment in an Anthem Blue Cross plan.

Calendar

COBRA Status

Medicare Status

Year

2013

How many full-time employees did your company have for at

How many employees did your company have for at

least 50% of the business days in the calendar year?

least 20 or more calendar weeks during the year?

________

Include

Exclude

________

Include

Exclude

Seasonal

Self-employed persons

Full-Time

Self-employed persons

Owners

Independent contractors

Part-Time

Independent contractors

Officers

Directors

Seasonal

Directors

Owners

Officers

How many part-time employees did your company have for at

least 50% of the business days in the calendar year?

Include

Exclude

Seasonal

Self-employed persons

Owners

Independent contractors

________

Officers

Directors

How many full-time equivalents (FTEs) can be derived from

________

the total number of full and part time employees listed above?

Please List SIC Code:



1 Full-Time Employee = 1 FTE



1 Part-Time Employee = a fraction of 1 FTE

________

Example:

1 Part-Time Employee works 10 hours per week = ¼ FTE

1 Part-Time Employee works 20 hours per week = ½ FTE

1 Part-Time Employee works 30 hours per week = ¾ FTE

3 Full-Time Employees work 40 hours per week = 3 FTEs

Company’s Total Full Time Equivalents = 4 ½ FTEs

Based on the information provided above, please indicate your group’s

Based on the information provided above, please indicate your

COBRA status:

group’s Medicare status:



Cal-COBRA (2 to 19 Full-Time Equivalents)

Medicare Prime (Less than 20 Full and Part-Time Employees)



Federal COBRA (20 or more Full-Time Equivalents)

Anthem Blue Cross Prime (20 or more Full and Part-time

Employees)

Should you have any questions regarding this form, please call your Anthem Blue Cross agent or Customer Service at 1-800-

627-8797.

______________________________________

____________________________________________________

Group Administrator’s Name (please print)

Group Administrator’s Signature

(_____)________________________________

(_____)_____________________________

_____________

Fax Number

Telephone Number

Date



Please check this box to allow Anthem Blue Cross to use the above data to ensure your group contact information is current.

02629CAEENABC 7/13

Cal Cobra Cobra And Medicare Survey - Anthem

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