Fillable COBRA Election Form ARP SUBSIDY

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COBRA Election Form ARP SUBSIDY

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NEW YORK HOTEL TRADES COUNCIL & HOTEL ASSOCIATION OF NYC, INC. EMPLOYEE BENEFIT FUNDS
West 44
th
Street • New York, NY 10036 • (212) 586-6400 • Fax: (212) 237-3061 • HotelFunds.org
COBRA Election Form – ARP SUBSIDY
Complete, sign and return this form to the COBRA Plan Administrator to elect COBRA coverage.
MEMBER INFORMATION:
FIRST NAME LAST NAME SOCIAL SECURITY NUMBER
XXX-XX-
If you are electing COBRA and you are not named above, enter your information below.
FIRST NAME LAST NAME RELATION TO MEMBER
ADDRESS CITY ST ZIP CODE
Select Coverage type: Individual Coverage Family Coverage
If you or any dependent(s) were totally disabled at the time
of loss of regular group coverage, list name(s) here:
Requirements for receiving COBRA under the American Rescue Plan Act of 2021 (ARP)
The participant must initial that he or she understands each item below:
_____ Have had an involuntary termination or reduction of hours of covered e
mployment during the period beginning
11/1/2019, and ending 9/30/2021.
_____ I am not eligible for other gr
oup health coverage (or I was not eligible for other group health plan coverage during
the period for which I am claiming premium assistance). I will notify the Funds immediately if group health coverage
becomes available.
_____ I am not eligible for Medi
care (or was not eligible for Medicare during the period for which I am claiming premium
assistance). I will notify the Funds immediately if Medicare health coverage becomes available.
_____ I elected (or am electing) COBRA continuation coverage
By signing below, I confirm that I wish to enroll myself and (if applicable) the above-
named dependents to a Subsidy COBRA
continuation coverage health insurance policy with the Health Benefits Fund. I confirm that I have read and understand the CO
BRA
continuation
coverage letter that accompanied this election form concerning my rights and responsibilities under COBRA. I
understand that I am obligated to immediately notify the Fund (or Employee Benefit Funds office) of any change of information
affects the hea
lth coverage eligibility of myself or any dependent(s). I understand that any person who knowingly files any claim or
application for coverage and/or for health benefits which contains false information or conceals information may have his or
her health
coverage revoked and may be subject to legal action to recover the amount of related losses incurred by the Fund, including att
orney's
fees and court costs.
Member's Signature Date (month/day/year)
To apply for ARP Premium Assistance, complete this form and return it to your plan or employer. If you have not
yet elected COBRA continuation coverage, you may send this form along with your Election Form. If you do not
complete this form and return it within 60 days of receipt, you may be unable to receive the premium assistance.
If you are already enrolled in COBRA, you may send this form in separately. If you choose to do so, send the
completed “Request for Treatment as an Assistance Eligible Individual” to: the COBRA Administrator, 305 West
44
th
Street, 2
nd
Floor, New York, NY 10036
You may also want to read the important information about the rules for premium assistance included in the
“Summary of the COBRA Premium Assistance Provisions Under the American Rescue Plan Act of 2021.”
NYHTC Health Benefits
Fund
REQUEST FOR TREATMENT AS AN ASSISTANCE
ELIGIBLE INDIVIDUAL
305 W 44
th
St
2
nd
Floor
New York, NY 10036
PERSONAL INFORMATION
Name and mailing address of employee (list any dependents on the
back of this form)
Telephone number
E-mail address (optional)
To qualify, you must be able to check ‘Yes’ for all statements.
1. The qualifying event was a loss of employment that was involuntary or a reduction in hours. Yes No
2. I elected (or am electing) COBRA continuation coverage. Yes No
3. I am NOT eligible for other group health plan coverage (or I was not eligible for other group health plan coverage
during the period for which I am claiming premium assistance).
Yes No
4. I am NOT eligible for Medicare (or I was not eligible for Medicare during the period for which I am claiming
premium assistance).
Yes No
I make an election to exercise my right to ARP premium assistance and attest that I meet the requirements for treatment as an
Assistance Eligible Individual. To the best of my knowledge and belief all of the answers I have provided on this form are true and
correct.
Signature __________________________________________________ Date ____________________________
Type or print name __________________________________________ Relationship to employee _________________________
FOR EMPLOYER OR PLAN USE ONLY
This request is: Approved Denied Specify reason in #3 below and return a copy of this form to the applicant.
REASON FOR DENIAL OF TREATMENT AS AN ASSISTANCE ELIGIBLE INDIVIDUAL
1. Loss of employment was voluntary.
2. Individual did not experience a reduction in hours.
3. Individual did not elect COBRA coverage.
4. Other (please explain)
Signature of employer, plan administrator, or other party responsible for COBRA administration for the Plan
__________________________________________________ Date ____________________________
Type or print name _____________________________________________________________________________
Telephone number ____________________________ E-mail address ____________________________
For Further Assistance, you may contact the Department of Labor’s Employee Benefits
Administration at 1-866-444-3272, or online at https://www.askebsa.dol.gov/WebIntake.
DEPENDENT INFORMATION (Parent or guardian should sign for minor children.)
Name Date of Birth Relationship to Employee SSN (Last 4-digits)
a. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage. Yes No
2. I am NOT eligible for other group health plan coverage. Yes No
3. I am NOT eligible for Medicare. Yes No
4. The qualifying event was an involuntary termination or a reduction in hours. Yes No
I make an election to exercise my right to ARP premium assistance. To the best of my knowledge and belief all of the answers I have
provided on this form are true and correct.
Signature __________________________________________________ Date ____________________________
Type or print name __________________________________________ Relationship to employee _________________________
Name Date of Birth Relationship to Employee SSN (Last 4-digits)
b. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage. Yes No
2. I am NOT eligible for other group health plan coverage. Yes No
3. I am NOT eligible for Medicare. Yes No
4. The qualifying event was an involuntary termination or a reduction in hours. Yes No
I make an election to exercise my right to ARP premium assistance. To the best of my knowledge and belief all of the answers I have
provided on this form are true and correct.
Signature __________________________________________________ Date ____________________________
Type or print name __________________________________________ Relationship to employee _________________________
Name Date of Birth Relationship to Employee SSN (Last 4-digits)
c. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage. Yes No
2. I am NOT eligible for other group health plan coverage. Yes No
3. I am NOT eligible for Medicare. Yes No
4. The qualifying event was an involuntary termination or a reduction in hours. Yes No
I make an election to exercise my right to the ARP premium assistance. To the best of my knowledge and belief all of the answers I
have provided on this form are true and correct.
Signature __________________________________________________ Date ____________________________
Type or print name __________________________________________ Relationship to employee _________________________
DEPENDENT INFORMATION (Parent or guardian should sign for minor children.)
Name Date of Birth Relationship to Employee SSN (Last 4-digits)
d. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage. Yes No
2. I am NOT eligible for other group health plan coverage. Yes No
3. I am NOT eligible for Medicare. Yes No
4. The qualifying event was an involuntary termination or a reduction in hours. Yes No
I make an election to exercise my right to ARP premium assistance. To the best of my knowledge and belief all of the answers I have
provided on this form are true and correct.
Signature __________________________________________________ Date ____________________________
Type or print name __________________________________________ Relationship to employee _________________________
Name Date of Birth Relationship to Employee SSN (Last 4-digits)
e. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage. Yes No
2. I am NOT eligible for other group health plan coverage. Yes No
3. I am NOT eligible for Medicare. Yes No
4. The qualifying event was an involuntary termination or a reduction in hours. Yes No
I make an election to exercise my right to ARP premium assistance. To the best of my knowledge and belief all of the answers I have
provided on this form are true and correct.
Signature __________________________________________________ Date ____________________________
Type or print name __________________________________________ Relationship to employee _________________________
Name Date of Birth Relationship to Employee SSN (Last 4-digits)
f. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage. Yes No
2. I am NOT eligible for other group health plan coverage. Yes No
3. I am NOT eligible for Medicare. Yes No
4. The qualifying event was an involuntary termination or a reduction in hours. Yes No
I make an election to exercise my right to the ARP premium assistance. To the best of my knowledge and belief all of the answers I
have provided on this form are true and correct.
Signature __________________________________________________ Date ____________________________
Type or print name __________________________________________ Relationship to employee _________________________
Summary of the COBRA Premium Assistance
Provisions under the American Rescue Plan Act of 2021
President Biden signed H.R. 1319, the American Rescue Plan Act of 2021 (ARP), on March 11, 2021. This law
subsidizes the full COBRA premium for “Assistance Eligible Individuals” for periods of coverage from April 1,
2021 through September 30, 2021.
To be eligible for the premium assistance, you:
MUST have a COBRA qualifying event that is a reduction in hours or an involuntary termination of a
covered employee’s employment;
MUST elect COBRA continuation coverage;
MUST NOT be eligible for Medicare; AND
MUST NOT be eligible for coverage under any other group health plan, such as a plan sponsored by a new
employer or a spouse’s employer.
IMPORTANT
◊ If you do not elect to receive the premium assistance within 60 days of receipt of this form, you may be
ineligible for the premium assistance.
◊ If you elect COBRA continuation coverage with premium assistance, and then become eligible for other
group health plan coverage (not including coverage that is only excepted benefits (such as dental or vision
coverage), a Qualified Small Employer Health Reimbursement Arrangement, or a health flexible spending
arrangement), or if you become eligible for Medicare, you MUST notify the plan in writing. If you fail to
provide this notice, you may be subject to a penalty of $250 (or if the failure is fraudulent, the greater of
$250 or 110% of the premium assistance provided after termination of eligibility). You won’t be subject to
the penalty if your failure to notify the plan is due to reasonable cause and not due to willful neglect.
◊ Employers that don’t satisfy COBRA continuation coverage requirements may be investigated by the
Department of Labor and may be subject to an excise tax under the Internal Revenue Code.
◊ If you elect COBRA continuation coverage and are eligible for the premium assistance, you cannot claim
the Health Coverage Tax Credit. You also cannot qualify for a premium tax credit to help pay for coverage
through a Health Insurance Marketplace
®1
, such as on HealthCare.gov, for any months that you are enrolled
in COBRA continuation coverage with or without the premium assistance.
For general information on your plan’s COBRA continuation coverage, contact the COBRA Administrator at
(212) 586-6400 or 305 West 44
th
Street, 2
nd
Floor, New York, NY 10036.
For specific information on your plan’s administration of the ARP premium assistance or to notify the plan of
your ineligibility to receive premium assistance, contact the COBRA Administrator at (212) 586-6400 or 305
West 44
th
Street, 2
nd
Floor, New York, NY 10036.
For more information regarding ARP premium assistance and eligibility questions, visit:
https://www.dol.gov/cobra-subsidy or contact the Department of Labor at askebsa.dol.gov or 1-866-444-EBSA
(3272)
This restriction does not include coverage under a plan that provides only excepted benefits, a qualified small employer health
reimbursment arrangement, or coverage under a health flexible spending arrangement.
1
Health Insurance Marketplace® is a registered service mark of the U.S. Department of Health & Human Services.
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COBRA Election Form ARP SUBSIDY

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Completed 14 April 2021

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