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Model Cal-COBRA Notices for Subsidy
The following forms may be used by health plans to comply with the AB 23 (Jones - Chapter 3, Statutes of 2009) and H.R. 3326 (Department of Defense Appropriations Act, 2010 –Public Law 111-1118) requirements to notify enrollees of the right to a subsidy under the American Recovery and Reinvestment Act of 2009. These model notices may be altered by health plans to include plan-specific information or to select options.
General Model Notice
This notice should be provided to every qualified beneficiary who experiences a qualifying event and must be provided with Cal-COBRA election materials after the enactment of HR 3326. This notice must be provided with 14 days of the date the health plan receives notice of the individual’s qualifying event pursuant to Health and Safety Code Section 1366.25.
General Model Notice (Word 2003 format).
Model Notice #1
This notice should be provided to Cal-COBRA enrollees who are currently paying reduced premiums and who have not exhausted the original nine months of subsidy. This notice must be provided by February 17, 2010 pursuant to H.R. 3326.
Model Notice #1 (Word 2003 format).
Model Notice #2
This notice should be provided to Cal-COBRA enrollees who exhausted the original nine months of subsidy and who are currently paying full, unsubsidized premiums. This notice must be provided within 60 days of the individual’s transition period pursuant to H.R. 3326.
Model Notice #2 (Word 2003 format).
Model Notice #3
This notice should be provided to individuals who exhausted their original nine months of subsidy and failed to make payments for subsequent coverage periods. This notice must be provided within 60 days of the individual’s transition period pursuant to H.R. 3326.
Model Notice #3 (Word 2003 format).
Model Notice #4
This notice should be provided to individuals who received Cal-COBRA election materials but were not provided with information regarding ARRA premium assistance. In most cases, this means qualified beneficiaries who experienced a qualifying event in December 2009, and whose coverage formally terminated on January 1, 2010. This notice must be provided within 60 days of the enactment of H.R. 3326. H.R. 3326 was enacted on December 19, 2009.
Model Notice #4 (Word 2003 format).
