COBRA Qualifying Event Notice Checklist This checklist from Mandated Health Benefits – The COBRA Guide is designed to help plan sponsors and administrators ensure that their COBRA qualifying event notices include the specific information required to comply with DOL’s COBRA notice regulations. Description of Item Is it Addressed?The name of the group health plan under which COBRA coverage is available; Yes Noand the name, address and telephone number of the party responsible under theplan for the administration of COBRA continuation coverage benefits (that is, Comments:such as a third-party administrator or insurance company representative).Identification of the qualifying event which is generating the notice. Yes No Comments:Identification, by status or name, of the qualified beneficiaries who are Yes Norecognized by the plan as being entitled to elect COBRA coverage regarding thequalifying event, and the date on which coverage under the plan will terminate Comments:(or has terminated) unless COBRA coverage is elected.A statement that: Yes No each individual who is a qualified beneficiary regarding the qualifying Comments: event has an independent right to elect COBRA coverage; a covered employee or a qualified beneficiary who is the spouse of the covered employee (or was the spouse of the covered employee on the day before the qualifying event occurred) may elect COBRA coverage on behalf of all other qualified beneficiaries regarding the qualifying event; and a parent or legal guardian may elect COBRA coverage on behalf of a minor child.An explanation of the plan’s procedures for electing COBRA coverage, Yes Noincluding an explanation of the time period during which the election must bemade, and the date by which the election must be made. Comments:An explanation of: Yes No the consequences of failing to elect or waiving COBRA coverage, Comments: including an explanation that a qualified beneficiary’s decision whether to elect COBRA coverage will affect the future rights of qualified beneficiaries to HIPAA portability benefits, guaranteed access to individual health coverage, and special enrollment rights under HIPAA, with a reference to where a qualified beneficiary may obtain additional information about these rights; and the plan’s procedures for revoking a waiver of the right to COBRA coverage before the date by which the election must be made.
A description of the COBRA coverage that will be made available under the Yes Noplan, if elected, including the date on which that coverage will commence. Thiscan be done either by providing a description of the coverage or by reference to Comments:the plan’s SPD.An explanation of: Yes No the maximum period for which COBRA coverage will be available under Comments: the plan, if elected; the COBRA coverage termination date; and any events that might cause COBRA coverage to be terminated earlier than the end of the maximum period.A description of the circumstances (if any) under which the maximum period of Yes NoCOBRA coverage may be extended due either to the occurrence of a secondqualifying event or a Social Security disability determination event, and the Comments:length of any such extension.If COBRA coverage has a maximum duration of less than 36 months, a Yes Nodescription of the plan’s requirements regarding the responsibility of qualifiedbeneficiaries to provide notice of a second qualifying event and notice of a Comments:Social Security Administration disability determination, along with a descriptionof the plan’s procedures for providing those notices, including the times withinwhich the notices must be provided and the consequences of failing to providethe notices. The notice must also explain qualified beneficiaries’ responsibilitiesto provide notice that a disabled qualified beneficiary has subsequently beendetermined to no longer be disabled.A description of the amount, if any, that each qualified beneficiary will be Yes Norequired to pay for COBRA coverage. Comments:A description of: Yes No the due dates for payments; Comments: the qualified beneficiaries’ right to pay on a monthly basis; the grace periods for payment; the address to which payments should be sent; and the consequences of delayed payment and non-payment.An explanation of the importance of keeping the administrator informed of the Yes Nocurrent addresses of all participants or beneficiaries under the plan who are ormay become qualified beneficiaries. Comments:
A summary of the 72.5-percent health coverage tax credit created by the TradeAct of 2002 that may be applicable to participants who could be eligible for trade Yes Noadjustment assistance or because they may be receiving payments from thePension Benefit Guaranty Corporation (PBGC-eligibles). [This explanation is Comments:not required in the DOL model notices but should be considered if the planadministrator believes employees might be affected.]A statement that the notice does not fully describe COBRA coverage or other Yes Norights under the plan, and that more complete information regarding such rightsis available in the plan’s SPD or from the plan administrator. Comments: