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General Information: If you or a family member has lost employment, a new law
may make it possible for you to keep your employment-related health coverage.
The American Recovery and Reinvestment Act of 2009 (ARRA) provides for premium
assistance for health benefits under the Consolidated Omnibus Budget
Reconciliation Act of 1985, commonly called COBRA. The premium assistance is
also available for continuation coverage under certain State laws. For coverage
periods beginning on or after February 17, 2009, assistance eligible individuals
pay only 35% of their continuation coverage premiums to the plan for the first
nine months. The remaining 65% is reimbursed to the plan, employer, or health
insurance issuer through a payroll tax credit.
To be eligible for assistance, you must meet All of the following
requirements:
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Be eligible for continuation coverage under COBRA or a State law that
provides comparable continuation coverage (for example, so-called “mini-COBRA”
laws) at any time during the period beginning September 1, 2008 and ending
December 31, 2009;
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Elect continuation coverage (when first offered or during the additional
election period); and
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Have a qualifying event for the continuation coverage that is the employee’s
involuntary termination during the period beginning September 1, 2008 and ending
December 31, 2009.
The applicant (person requesting review of a denial of premium assistance)
may either be the former employee or a member of the employee’s family who is
eligible for COBRA continuation coverage or the COBRA premium assistance through
an employment-based health plan. The employee and his/her family members may
each elect to continue health coverage under COBRA, request the premium
assistance, and request a review of a denial of premium assistance.
If you believe you are eligible for COBRA continuation coverage and for this
premium reduction through a private sector health plan sponsored by an employer
generally with at least 20 employees, but your request for these benefits or the
reduced premium has been denied, you may apply to the U.S. Department of Labor
to review the denial. If your continuation coverage is provided through a
Federal, State or local government plan, or if it is provided pursuant to State
insurance law, you should direct your request for review to the Department
of Health and Human Services.
Applying For Review: Answer all of the questions on the application to the
best of your knowledge and ability. If you don’t know the answer to a question
you may check the box marked “Unsure or N/A.” (N/A stands for “not
applicable.”) Please include copies of any documents that you think would help
the Department in its review of your application, examples of which are listed
in the attached instructions. Provide your complete contact information (daytime
phone number, an alternate phone number, and an email address, if available) so
that the person reviewing your application can contact you with any questions or
if additional information is needed. The Department of Labor will not review
your denial until you submit a properly completed application form. A separate
application(s) must be completed for any family member whose plan information is
not identical to the information you provide. Keep a copy of the application(s)
submitted for your records. Note: In the course of its review, the Department
may need to share information on this application with your employer or plan
administrator.
You are encouraged to complete your application online
or you can fax or mail the completed application, along with your attachments,
to:
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Fax to:
U.S. Department of Labor
Employee Benefits Security Administration
Attn: COBRA Appeals
Fax number: 202.693.8849
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Mail to:
U.S. Department of Labor
Employee Benefits Security Administration
Attn: COBRA Appeals
P.O. Box 78038
Washington, DC 20013-9038
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For Assistance: If you have questions on how to complete this form or about
eligibility for COBRA or the COBRA premium reduction, please see our web site at
www.dol.gov/COBRA. You may also call a DOL benefits advisor toll-free at
1.866.444.3272. Benefits advisors can assist you with questions, but cannot
complete or take your application for review by phone.
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