HOW TO COMPLETE THIS FORM
SECTION 1 – Notification (To be completed by the Designated Employer Representative)
Note: The designated employer representative must inform the Enrollee of their COBRA election rights
1. Date of Notice: Date the Qualified Beneficiary is notified of his/her COBRA rights.
2. UHA Benefits Termination Date: The Date that the covered employee and/or spouse and dependents will no longer be eligible for coverage under the group’s plan for
active subscribers (Normally the end of the month following the qualifying event).
3. Name: Name of the Qualified Beneficiary who is eligible for COBRA coverage.
4. Employee Name: If different from #3, the name of the employee.
5. Social Security Number: The 9-digit number under which COBRA benefits are to be paid (For example, the SSN of a child who is currently enrolling under COBRA,
who may have been previously covered under a parent’s SSN).
6. Return and completion instructions: Return address for the Designated Employer Representative and date the COBRA Enrollee must return the UHA COBRA
Continuation Coverage Election Form and first month’s premium payment (if electing COBRA coverage) to the Designated Employer Representative. The return date
should be 60 days from the date of the Qualifying event or 60 days from the Date of Notice, whichever is later.
7. Qualifying COBRA Event: Check one. For covered employees, spouses or dependent children: Termination of employment for reasons other than “gross misconduct,’
Retirement from employment, Reduction in hours of employment or Certified disabled by Social Security Act (SSA). For spouses or dependent children: Divorce/Legal
Separation of a spouse from a covered employee, Death of a covered employee, Loss of dependent child status or Covered employee’s coverage under Medicare.
8. Date of Qualifying Event: The Date that the qualifying event occurred.
9. Date COBRA Coverage to Begin: The Date that the covered employee and/or spouse and dependents will be eligible to receive COBRA benefits (COBRA regulations
do not allow a break in coverage. Coverage must and shall begin immediately following the termination from the group’s plan for active subscribers).
10. Current monthly COBRA Rates: Current monthly COBRA rates provided by UHA, which represents 102% of the applicable premium. For individuals determined to be
disabled (See #7 above) the COBRA rate for the additional 11 months of continued COBRA coverage may be increased to 150% of the applicable premium.
11. Group Name: Name of the Group or company.
12. UHA Group / COBRA Division Number: UHA group number and applicable COBRA division number.
13. Designated Employer Representative: Name of the designated Employer Representative completing the UHA COBRA Continuation Coverage Election Form.
14. Designated Phone Number: Phone number of the designated Employer Representative completing the UHA COBRA Continuation Coverage Election Form.
SECTION 2 – Election of COBRA Benefits (To be completed by the Covered Employee and/or Spouse and Dependents)
Election to accept COBRA: Check the election box to accept continuation of coverage. This also indicates that the person checking the box accepts the following:
Responsibility to pay for the full cost of the coverage
Coverage will be terminated if payment is not received
COBRA rate changes based upon contracted changes in benefits and rates of the employer
group plan
Coverage will be cancelled if payment is not received by the first of the month. Coverage will be reinstated retroactively to the beginning of the month once payment is
received in full within the current month. (See COBRA Payment Procedures)
15. Individuals to be enrolled: Who will be enrolled in COBRA, including their A) Relationship to employee, B) Gender, C) Full Name, D) Social Security Number, E) Birth
date, F) Social Security Disability
Signature of COBRA Enrollee: Signature of the person enrolling in COBRA or their legal guardian, including phone number and mailing address.
Election to decline COBRA: Check box if you or your dependents will not be enrolling in COBRA.
Signature: Signature of the person qualified for COBRA to decline coverage or their legal guardian.
COBRA ENROLLEE: Return your completed form along with your first month’s premium payment (if you are choosing COBRA coverage) to the Designated
Employer Representative at the address listed on #6 above. All payments after the initial payment should be sent directly to UHA (see payment procedure below).
DESIGNATED EMPLOYER REPRESENTATIVE: Please submit completed form and initial payment (if applicable) to the address listed on #3 below.
UHA COBRA PAYMENT PROCEDURES
MONTHLY PREMIUM PAYMENT
1. The COBRA Enrollee is responsible to pay for their COBRA coverage. They will not have eligibility until payment for the current month is received in full. The
COBRA monthly billing rates, which represents 102% of the group plan’s premium, are subject to change upon the former employer group’s contracted
renewal.
2. A COBRA monthly billing statement will be mailed to you after the initial payment is received. UHA’s COBRA monthly billing statement is sent as a courtesy reminder of
when payment is due. Payment is due whether or not a billing statement is received.
3. Payment stub with check made payable to UHA should be sent to: UHA – COBRA
700 Bishop Street, Suite 300
Honolulu, HI 96813
4. Payment can also be made by Electronic Funds Transfer (EFT) or Credit card. EFT forms are available on our website, uhahealth.com. Please contact UHA Enrollment
Services at (808) 532-4000 ext. 299 for more information regarding credit card payments or any other questions. Notification to terminate your automatic deduction is
required by the 25
th
of the month. Should UHA be notified after this date and payment is deducted, a refund will be processed which may take up to two weeks.
5. Coverage will be cancelled until full payment for the month is received. UHA does not accept postdated checks or checks for an amount less than the
premiums owed.
6. Coverage will be terminated if an enrollee’s check is returned and proper payment is not received by the end of the current month (see #5 above).
7. If coverage is cancelled and payment remains past due beyond the last day of the month due, coverage cannot be reinstated and the account will remain cancelled.
BENEFITS
Benefits for the COBRA Enrollee will be the same as those offered in the group’s plan for active subscribers. If the group’s plan has any benefit and/or rate changes,
COBRA Enrollees will be affected. The group’s plan administrator or Designated Employer Representative should notify COBRA Enrollees of any changes.
CLAIMS
Claims must be submitted using the COBRA Group/Division number and the COBRA enrollee’s member ID number. In most cases, medical offices will prepare all
claims on behalf of covered persons.
TERMINATION
COBRA eligibility will terminate for the following reasons:
o Coverage as an employee or as a dependent under any group health plan that does not contain any exclusions or limitations for any pre-existing conditions
which you, your spouse or dependents may have;
o Payment is not made on time;
o The COBRA member meets the maximum length of coverage for their qualifying COBRA event;
o The group terminates their group plan;
o
Coverage under Medicare (if Medicare becomes effective following COBRA coverage effective date).
