The Department of Labor has developed a model Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA) continuation coverage election notice that the Plan may use to provide the election notice. To use
this model election notice properly, the Plan Administrator must ll in the blanks with the appropriate plan
information. The Department considers use of the model election notice to be good faith compliance with
the election notice content requirements of COBRA. The use of the model notices isn’t required. The model
notices are provided to help facilitate compliance with the applicable notice requirements.
This version of the model notice includes federally-required information for your employees about other
coverage options besides COBRA, including coverage through the Massachusetts Health Connector. Mas-
sachusetts employers are not required to use this or any specic model template. However, this template
was generated to provide an easy way for Massachusetts employers to satisfy their federal COBRA noticing
responsibilities and also inform employees about Massachusetts-specic coverage alternatives, which may
be more affordable.
Note: Plans do not need to include this instruction page with the model election notice.
Paperwork Reduction Act statement
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to
respond to a collection of information unless such collection displays a valid Ofce of Management and
Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a
collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB
control number, and the public is not required to respond to a collection of information unless it displays a
currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law,
no person shall be subject to penalty for failing to comply with a collection of information if the collection of
information does not display a currently valid OMB control number. See 44 U.S.C. 3512.
The public reporting burden for this collection of information is estimated to average approximately four
minutes per respondent. Interested parties are encouraged to send comments regarding the burden
estimate or any other aspect of this collection of information, including suggestions for reducing this bur-
den, to the U.S. Department of Labor, Ofce of Policy and Research, Attention: PRA Clearance Ofcer, 200
Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference
the OMB Control Number 1210-0123.
OMB Control Number 1210-0123 (expires 10/31/2016)
Instructions:
Massachusetts-Specic Model
COBRA Continuation Coverage Election Notice
For use by Massachusetts Employers and Employees
Date:
Dear:
This notice has important information about your right to continue your health care coverage in
(enter name of group health plan):
[the Plan], as well as other health coverage options that may be available to you, including coverage
through our state’s Health Insurance Marketplace, the Massachusetts Health Connector.
Learn more about the Health Connector at MAhealthconnector.org, or by calling 1-877 MA ENROLL (877-
623-6765) or TTY: 1-877-623-7773. You may be able to get coverage through the Massachusetts Health
Connector that costs less than COBRA continuation coverage. All of the health plans offered by the Health
Connector meet the state’s standards for quality and value. You may also wish to shop for a health plan
directly from an insurance carrier.
Please read the information in this notice very carefully before you make your decision. If you choose to
elect COBRA continuation coverage, you should use the election form provided later in this notice.
Why am I getting this notice?
You’re getting this notice because your coverage under the Plan will end on:
due to (check appropriate box):
End of employment Reduction in hours of employment
Death of employee Divorce or legal separation
Entitlement to Medicare Loss of dependent child status
Federal law requires that most group health plans (including this Plan) give employees and their families
the opportunity to continue their health care coverage through COBRA continuation coverage when there’s
a “qualifying event” that would result in a loss of coverage under an employer’s plan.
What is COBRA continuation coverage?
COBRA continuation coverage is the same coverage that the Plan gives to other participants or
beneciaries who aren’t getting continuation coverage. Each “qualied beneciary” (described below)
who elects COBRA continuation coverage will have the same rights under the Plan as other participants or
beneciaries covered under the Plan.
IMPORTANT INFORMATION:
COBRA Continuation Coverage and other
Health Coverage Alternatives Available to
Massachusetts Residents
Who are the qualied beneciaries?
Each person (“qualied beneciary”) in the category/categories checked below can elect COBRA
continuation coverage:
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
Are there other coverage options besides COBRA?
Yes. Instead of enrolling in COBRA continuation coverage, there may be other more affordable coverage
options for you and your family through the Massachusetts Health Connector, MassHealth (our state’s
Medicaid program), other group health plan coverage options (such as a spouse’s plan), or an individual
plan directly from an insurance carrier. You may be able to enroll in one of these programs during a special
enrollment period following a qualifying event (such as losing your coverage through an employer). Some
of these options may cost less than COBRA continuation coverage. There is more information below on the
Massachusetts Health Connector and the coverage options available to you there.
You should compare your other coverage options with COBRA continuation coverage and choose the
coverage that is best for you. For example, if you move to other coverage you may pay more out of pocket
than you would under COBRA because the new coverage may impose a new deductible, though it may
require a lower monthly premium. However, there are many types of health and dental plans to choose
from at the Health Connector, and you can select the plan that’s right for you and your family.
When you lose job-based health coverage, it’s important that you choose carefully between COBRA
continuation coverage and other coverage options, because once you’ve made your choice, it can be
difcult or impossible to switch to another coverage option.
If I elect COBRA continuation coverage, when will my coverage begin and how long will
it last?
If elected, COBRA continuation coverage will begin on:
and can last until:
Continuation coverage may end before the date noted above in certain circumstances, like failure to pay
premiums, fraud, or the individual becomes covered under another group health plan.
You may elect any of the following options for COBRA continuation coverage:
(list available coverage options or N/A if not applicable)
Can I extend the length of COBRA continuation coverage?
If you elect continuation coverage, you may be able to extend the length of continuation coverage if a
qualied beneciary is disabled, or if a second qualifying event occurs. A qualifying event, such as adding
a dependent through marriage or the birth of a child, or loss of other health insurance coverage, generally
allows for a special enrollment period outside of open enrollment.
You must notify the following contact of a disability or a second qualifying event within a certain time period
to extend the period of continuation coverage:
If you don’t provide notice of a disability or second qualifying event within the required time period, it will
affect your right to extend the period of continuation coverage.
For more information about extending the length of COBRA continuation coverage visit:
www.dol.gov/ebsa/publications/cobraemployee
How much does COBRA continuation coverage cost?
COBRA continuation coverage will cost: $
(enter amount each qualied beneciary will be required to pay for each option per month of coverage and
any other permitted coverage periods.)
Other coverage options may cost less. If you choose to elect continuation coverage, you don’t have to send
any payment with the Election Form. Additional information about payment will be provided to you after the
election form is received by the Plan. Important information about paying your premium can be found at
the end of this notice.
You may be able to get coverage through the Massachusetts Health Connector that costs less than
COBRA continuation coverage. You can learn more about the Health Connector below.
What is the Massachusetts Health Connector?
The Massachusetts Health Connector is a Marketplace offering “one-stop shopping” to nd and compare
private health insurance options. When you shop for a plan through MAhealthconnector.org, you can see
what your premium and out-of-pocket costs (such as co-pays, deductible, co-insurance) will be before you
make a decision to enroll.
When you apply through the Massachusetts Health Connector, you could qualify for help paying for your
health insurance, through a tax credit that lowers your monthly premiums, or a ConnectorCare plan, with a
lower monthly premium and lower out-of-pocket costs. If you apply through MAhealthconnector.org, you can
also learn if you qualify for free or low-cost coverage from MassHealth (Massachusetts’ Medicaid program)
or the Children’s Health Insurance Program (CHIP). If you live outside of Massachusetts, you can access
the Marketplace for your state at www.HealthCare.gov.
If you live outside of Massachusetts, you can access the Marketplace for your state at www.HealthCare.gov.
Coverage through the Massachusetts Health Connector may cost less than COBRA continuation coverage.
Being offered COBRA continuation coverage won’t limit your eligibility for coverage or for a tax credit,
however, if you enroll in COBRA coverage, it will affect your eligibility through the Health Connector.
Visit MAhealthconnector.org or call 1-877 MA ENROLL (1-877-623-6765) or TTY 1-877-623-7773 for more
information.
You can also check out the Health Connector’s website for information on their plans and the types
of savings opportunities that might be available to you. Your employer can also help provide you with
materials and brochures that describe coverage options through the Health Connector.
For in-person help, you can work with a Navigator or a Certied Application Counselor at a local hospital
or community health center. They have been trained to help you with the application process. For a list of
people in your area, visit MAhealthconnector.org or call Customer Service at the number above.
When can I enroll in Health Connector coverage?
You have 60 days from the time you lose your job-based coverage to enroll in the Health Connector. That is
because losing your job-based health coverage is a qualifying event, which allows you a special enrollment
period. After 60 days your special enrollment period will end and you may not be able to enroll, so you
should take action right away. In addition, during what is called an “open enrollment” period, anyone can
enroll in Health Connector coverage.
To nd out more about enrolling through the Health Connector, such as when the next open enrollment
period will be and what you need to know about qualifying events and special enrollment periods, visit
MAhealthconnector.org.
Can I switch back and forth between COBRA continuation coverage and coverage
through the Health Connector?
If you sign up for COBRA continuation coverage, you can switch to a Health Connector plan during an
open enrollment period. You can also end your COBRA continuation coverage early and switch to a Health
Connector plan if you have another qualifying event such as marriage or birth of a child. But be careful
though—if you terminate your COBRA continuation coverage early without another qualifying event, you’ll
have to wait to enroll in Health Connector coverage until the next open enrollment period, and could end up
without any health coverage in the meantime.
Once you’ve exhausted your COBRA continuation coverage and the coverage expires, you’ll be eligible
to enroll in Health Connector coverage through a special enrollment period, even if open enrollment has
ended.
If you sign up for Health Connector coverage instead of COBRA continuation coverage, you cannot switch to
COBRA continuation coverage under any circumstances.
Can I enroll in another group health plan?
You may be eligible to enroll in coverage under another group health plan (such as a spouse’s plan), if you
request enrollment within 30 days of the loss of coverage.
If you or your dependent chooses to elect COBRA continuation coverage instead of enrolling in another
group health plan for which you’re eligible, you’ll have another opportunity to enroll in the other group
health plan within 30 days of losing your COBRA continuation coverage.
What factors should I consider when choosing coverage options?
When considering your options for health coverage, you may want to think about:
Premiums. Your previous plan can charge up to 102% of total plan premiums for COBRA coverage.
Other options, like coverage on a spouse’s plan or through the Marketplace, may be less expensive.
Provider networks: If you’re currently getting care or treatment for a condition, a change in your health
coverage may affect your access to a particular health care provider. You may want to check to see if
your current health care providers participate in a network as you consider options for health coverage
Prescription drugs: If you’re currently taking medication, a change in your health coverage may affect
your costs for medication—and in some cases, your medication may not be covered by another plan.
You may want to check to see if your current medications are listed in drug formularies for other health
coverage.
Severance payments: If you lost your job and got a severance package from your former employer, your
former employer may have offered to pay some or all of your COBRA payments for a period of time. In
this scenario, you may want to contact the Department of Labor at 1-866-444-3272 to discuss your
options.
Service areas: Some plans limit their benets to specic service or coverage areas—so if you move to
another area of the country, you may not be able to use your benets. You may want to see if your plan
has a service or coverage area, or other similar limitations.
Other cost sharing: In addition to premiums or contributions for health coverage, you probably pay
co-payments, deductibles, co-insurance, or other amounts as you use your benets. You may want to
check to see what the cost-sharing requirements are for other health coverage options. For example,
one option may have much lower monthly premiums, but a much higher deductible and higher co-
payments.
For more information
This notice doesn’t fully describe continuation coverage or other rights under the Plan. More information
about continuation coverage and your rights under the Plan is available in your summary plan description
or from the Plan Administrator.
If you have questions about the information in this notice, your rights to coverage, or if you want a copy of
your summary plan description, contact:
(enter name of party responsible for COBRA administration for the Plan, with telephone number and
address)
For more information about your rights under the Employee Retirement Income Security Act (ERISA),
including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health
plans, visit the U.S. Department of Labor’s Employee Benets Security Administration (EBSA) website at
www.dol.gov/ebsa or call their toll-free number at 1-866-444-3272.
For more information about health insurance options available through the Massachusetts Health
Connector, and to locate a Navigator or Certied Application Counselor in your area who you can talk to
about the different options, visit MAhealthconnector.org.
Keep your Plan informed of address changes
To protect your and your family’s rights, keep the Plan Administrator informed of any changes in your
address and the addresses of family members. You should also keep a copy of any notices you send to the
Plan Administrator.
COBRA Continuation Coverage Election Form
The following people elect COBRA continuation coverage in the Plan:
Date of Birth:
SSN (or other identier):
Person 1:
Name:
Relationship to Employee:
(Add if appropriate) Coverage option elected:
Date of Birth:
SSN (or other identier):
Person 2:
Name:
Relationship to Employee:
(Add if appropriate) Coverage option elected:
Date of Birth:
SSN (or other identier):
Person 3:
Name:
Relationship to Employee:
(Add if appropriate) Coverage option elected:
Employee Signature Date
Print Name:
Date of Birth:
SSN (or other identier):
Person 4:
Name:
Relationship to Employee:
(Add if appropriate) Coverage option elected:
Date of Birth:
SSN (or other identier):
Person 5:
Name:
Relationship to Employee:
(Add if appropriate) Coverage option elected:
Important information about payment
Your rst payment and all periodic payments for COBRA coverage should be sent to:
First payment for COBRA continuation coverage
You must make your rst payment for COBRA coverage no later than 45 days after the date of your election
(this is the date the Election Notice is postmarked). If you don’t make your rst payment in full within
45 days of the date of your election, you’ll lose all continuation coverage rights under the Plan. You’re
responsible for making sure that the amount of your rst payment is correct.
Contact the Plan Administrator or other party responsible for COBRA administration under the Plan, listed
below, to conrm the correct amount of your rst payment:
Periodic payments for continuation coverage
After you make your rst payment for continuation coverage, you’ll have to make periodic payments for
each coverage period that follows. The amount due for each coverage period for each qualied beneciary
is shown in this notice.
For plans with monthly payment due dates:
The periodic payments can be made on a monthly basis. Under the Plan, each of these periodic payments
for continuation coverage is due for that coverage period by the:
For plans with other payment schedules:
You may instead make payments for COBRA coverage for the following coverage periods, due on the
following dates:
If you make a periodic payment on or before the rst day of the coverage period to which it applies, your
coverage under the Plan will continue for that coverage period without any break.
The Plan will will not send periodic notices of payments due for these coverage periods.
Grace periods for periodic payments
Although periodic payments are due on the dates shown above, you’ll be given a grace period after the rst
day of the coverage period [or] to make each periodic payment.
Your grace period will be either: 30 days OR (enter longer period permitted by Plan)
You’ll get COBRA coverage for each coverage period as long as payment for that coverage period is made
before the end of the grace period.
Check box if Plan suspends coverage during grace period for nonpayment:
For Plans that suspend coverage during grace period for nonpayment:
If you pay a periodic payment later than the rst day of the coverage period to which it applies, but before
the end of the grace period for the coverage period, your coverage will be suspended as of the rst day of
the coverage period, and then retroactively reinstated (going back to the rst day of the coverage period)
when your payment is received. Any claim you submit for benets while your coverage is suspended may
be denied and may have to be resubmitted once your coverage is reinstated. If you don’t make a payment
before the end of the grace period, you’ll lose all rights to COBRA coverage under the Plan.
of each month