Sample COBRA notices for employers

[Plan administrator name] [Plan administrator address] [City, State ZIP] [Date] [Recipient name] [Recipient address] [City, State ZIP] Re: COBRA continuation coverage under [Plan name] Dear [Recipient name]: We received your notice dated [date of recipient's notice] regarding [describe the event the recipient reported, for example: "your divorce from [employee name] effective [date]" or "your request for the disability extension based on a Social Security disability determination"]. After reviewing your request, we have determined that you are not entitled to [COBRA continuation coverage / the disability extension / the second qualifying event extension] under [Plan name]. The reason is: [Explain in plain language. Examples: "You were not enrolled in the Plan on the day before the event you describe." or "The event you describe is not a qualifying event under federal COBRA rules." or "Your notice was received more than 60 days after the event, which is past the deadline set by the Plan." or "We have not received a Social Security Administration determination that you are disabled within the first 60 days of COBRA coverage."] If you believe this determination is incorrect, please contact us in writing at the address above or by phone at [phone number]. You may have other coverage options available, including the Health Insurance Marketplace at HealthCare.gov, Medicaid, your spouse's employer plan, or another group plan. Loss of coverage is a special enrollment event for the Marketplace and for many group plans. Sincerely, [Plan administrator signer name] [Title] [Plan name] [Phone] · [Email]

[Plan administrator name] [Plan administrator address] [City, State ZIP] [Date] [Recipient name] [Recipient address] [City, State ZIP] Re: Early termination of COBRA continuation coverage under [Plan name] Dear [Recipient name]: This notice is to inform you that your COBRA continuation coverage under [Plan name] will end (or has ended) earlier than the maximum coverage period. Coverage end date: [Coverage end date] Reason for early termination: [Pick one and customize. Examples: - "We did not receive your premium payment for [month] by the end of the 30-day grace period that ended on [date]." - "We received notice that you became covered under another group health plan, [other plan name], effective [date]." - "We received notice that you became entitled to Medicare on [date]." - "[Plan name] has been terminated by the employer effective [date], and the employer is not offering a similar group health plan to active employees." - "The Social Security Administration has determined that you are no longer disabled, so the disability extension that increased your coverage period to 29 months no longer applies." - "Your coverage was terminated for [describe the conduct, for example, "submission of a fraudulent claim"], which would also justify terminating an active employee's coverage under the Plan's standard rules."] Other coverage options: [If the plan offers a conversion right, include this paragraph:] You have the right to convert your group coverage to an individual policy under [Plan name]. To exercise this right, you must [describe the conversion procedure, including any deadline and where to apply]. See the separate Conversion Notice for details. You may also have other coverage options through the Health Insurance Marketplace at HealthCare.gov, Medicaid, your spouse's employer plan, or another group plan. Loss of COBRA coverage is a special enrollment event for the Marketplace and for many other group plans. Marketplace coverage may cost less than COBRA or a conversion policy. If you believe this determination is incorrect, please contact us in writing at the address above or by phone at [phone number]. Sincerely, [Plan administrator signer name] [Title] [Plan name] [Phone] · [Email]

[Plan administrator name] [Plan administrator address] [City, State ZIP] [Date] [Recipient name] [Recipient address] [City, State ZIP] Re: COBRA premium payment shortfall for [period of coverage, for example, "January 2026"] Dear [Recipient name]: We received your COBRA continuation coverage premium payment for [period of coverage] on [date received]. Thank you. Your payment was for [amount received]. The required premium for that period of coverage is [required premium amount]. Your payment is short by [deficiency amount]. Under federal COBRA rules, a shortfall of this size is small enough that the plan may either accept it as full payment or ask you to make up the difference. We are asking you to make up the difference. To keep your COBRA continuation coverage in force for [period of coverage], please send the additional [deficiency amount] so that we receive it by [deadline date, which should be at least 30 days after the date of this notice]. Send payment to: [Payment mailing address] Acceptable payment methods: [for example: personal check, cashier's check, money order, electronic transfer to [account info if applicable]]. Make any check payable to [payee name]. If we do not receive [deficiency amount] by [deadline date], your COBRA continuation coverage may be terminated retroactively to the first day of the period of coverage that was not fully paid. If coverage is terminated, we may refund the [amount received] that was not enough to keep coverage in force, less any claims paid during the period. If you have questions, please contact us at [phone number] or [email]. Sincerely, [Plan administrator signer name] [Title] [Plan name] [Phone] · [Email]

[Plan administrator name] [Plan administrator address] [City, State ZIP] [Date] [Recipient name] [Recipient address] [City, State ZIP] Re: [Plan year, for example, "2027"] COBRA premium and open enrollment under [Plan name] Dear [Recipient name]: This notice describes changes to your COBRA continuation coverage that take effect on [new plan year start date], and the open enrollment options available to you. NEW COBRA PREMIUM Beginning [new plan year start date], the COBRA continuation coverage premium under [Plan name] will be: Self only: [$ amount] per month Self plus spouse: [$ amount] per month Self plus child(ren): [$ amount] per month Family: [$ amount] per month Your current coverage tier is [current tier], so your new monthly premium is [$ amount for current tier]. The new premium reflects the underlying group rate plus the federally permitted [2% / 50% if disability extension] administrative fee. Send your premium payment to: [Payment mailing address] Premium is due on the first day of each month, with a 30-day grace period. OPEN ENROLLMENT OPTIONS Active employees of [Employer name] are participating in open enrollment for the [plan year] plan year between [open enrollment start date] and [open enrollment end date]. As a qualified beneficiary on COBRA, you have the same right to change benefit packages during this window. The benefit packages available to you are: [List the packages available, with brief descriptions. Examples: - "Plan A: PPO, broad provider network, higher premium, lower out-of-pocket." - "Plan B: HMO, narrower network, lower premium." - "Plan C: HDHP with HSA-eligibility, lowest premium, highest deductible."] Detailed plan documents and Summary of Benefits and Coverage (SBC) for each option are available at [link or contact]. To change your benefit package for the new plan year, complete the enclosed Election Change Form and return it to [return address or email] so that we receive it by [open enrollment deadline]. If you do not respond, your current coverage will continue at the new premium amount shown above. No action is needed to stay on your current package. If you have questions, please contact us at [phone number] or [email]. Sincerely, [Plan administrator signer name] [Title] [Plan name] [Phone] · [Email]

[Plan administrator name] [Plan administrator address] [City, State ZIP] [Date] [Recipient name] [Recipient address] [City, State ZIP] Re: Right to convert your group coverage under [Plan name] Dear [Recipient name]: Your COBRA continuation coverage under [Plan name] is scheduled to end on [maximum coverage end date]. This notice describes your right to convert from group coverage to an individual policy. YOUR CONVERSION RIGHT [Plan name] offers eligible participants the right to convert from group coverage to an individual policy when group coverage ends, including at the end of COBRA. You have this right. THE CONVERSION POLICY The conversion policy is issued by [carrier name]. The conversion policy [describe the coverage at a high level. Conversion policies are often more limited than the group plan, with different deductibles, networks, or covered services.]. The premium for the conversion policy will be approximately [$ estimated monthly premium] per month, based on your current coverage tier ([self only / self plus spouse / family]). The carrier will confirm the exact premium when you apply. HOW TO APPLY To enroll in the conversion policy, you must apply by [conversion application deadline, typically 31 to 62 days after COBRA ends]. To apply: 1. Contact the carrier at [carrier phone] or [carrier website]. 2. Request a "conversion application." 3. Complete and return the application along with the first month's premium. You do not need to submit medical information for the conversion policy. The right to convert is guaranteed under the Plan and federal COBRA rules, regardless of your health status at the time you apply. OTHER OPTIONS WORTH COMPARING Before you decide, compare the conversion policy with other coverage available to you, including: · The Health Insurance Marketplace at HealthCare.gov. Loss of COBRA is a special enrollment event. Premium tax credits may apply based on income. · Medicaid in your state, if eligible. · Your spouse's employer plan, which may have a special enrollment window when COBRA ends. · A new employer plan, if you are working. Marketplace plans are often less expensive than conversion policies and may offer better coverage. If you have questions about the conversion policy, contact the carrier directly. For questions about your COBRA coverage end date, contact us at [phone number] or [email]. Sincerely, [Plan administrator signer name] [Title] [Plan name] [Phone] · [Email]

[Plan administrator name] [Plan administrator address] [City, State ZIP] [Date] [Recipient name] [Recipient address] [City, State ZIP] Re: Right to elect [State] state continuation coverage under [Plan name] NOTICE OF [STATE] STATE CONTINUATION COVERAGE RIGHTS ([STATE] STATE MINI-COBRA, NOT FEDERAL COBRA) Dear [Recipient name] and all other qualified beneficiaries, if any: [Plan name] is sponsored by [Employer name]. Because [Employer name] is below the federal COBRA threshold, federal COBRA does not apply to this Plan. However, [State] state law gives you the right to continue your group health coverage for a limited period after a qualifying event. This is sometimes called "[state-specific name, for example: Cal-COBRA, New York continuation, Texas state continuation]." This notice describes your rights under [State] law. Read it carefully. State continuation rights are set by state law and differ from federal COBRA rights. QUALIFYING EVENT The qualifying event that affects your coverage is: [describe the event, for example: "termination of your employment on [date]," "reduction in your hours below the eligibility threshold on [date]," "your divorce from the covered employee on [date]," "your loss of dependent status on [date]"]. Your coverage under [Plan name] [will end / ended] on: [coverage end date]. YOUR RIGHT TO ELECT STATE CONTINUATION COVERAGE You have the right to elect state continuation coverage under [State] law. To elect, complete the enclosed Election Form and return it so that we receive it by: Election deadline: [election deadline, set by state law. Common patterns: 30 days from the date of this notice, or 60 days from the qualifying event, but check your state.] If we do not receive your Election Form by the election deadline, you lose your right to state continuation coverage. MAXIMUM CONTINUATION PERIOD Under [State] law, the maximum period of state continuation coverage for your qualifying event is [number] months. The maximum coverage period [will end on / would end on] [end date], assuming all premiums are paid on time. PREMIUM AND HOW TO PAY The premium for state continuation coverage is: [$ amount] per month for [coverage tier, for example: self only, self plus spouse, family] This is [102% / other state-specific percentage] of the cost of coverage. [State law sets the maximum premium and may or may not allow an administrative fee. Confirm what your state allows.] Send your premium payment to: [Payment mailing address] Your first premium payment is due: [first premium due date, set by state law. Often 30 to 45 days after election.] Subsequent premium payments are due [monthly / other schedule] on [due date]. The grace period for late payments is [number] days. [State law sets the grace period.] WHEN STATE CONTINUATION COVERAGE MAY END EARLY Your state continuation coverage may end before the maximum period if: · You do not pay a premium by the end of the grace period. · [Plan name] ends entirely. · You become covered under another group health plan. · You become entitled to Medicare. · [Other reasons specified by state law. Check your state.] OTHER COVERAGE OPTIONS WORTH COMPARING You may have other coverage options that cost less than state continuation. Compare with: · The Health Insurance Marketplace at HealthCare.gov. Loss of coverage is a special enrollment event. Premium tax credits may apply based on income. · Your spouse's employer plan, if applicable. Loss of your coverage is usually a qualifying event for them too. · Medicaid in your state, if eligible. · CHIP for dependent children, if eligible. CONTACT INFORMATION If you have questions about this notice or about [Plan name], please contact us at [phone number] or [email]. For information about your continuation-coverage rights under [State] law, contact the [State] Department of Insurance. [Look up your state's department using the resources cited below.] Sincerely, [Plan administrator signer name] [Title] [Plan name] [Phone] · [Email]