2021 COBRA Subsid
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American Rescue Plan Act
721 South Parker, Suite 200, Orange, CA 92868
800
558-8003 www.calchoice.com
•
uthorized Group Contact Signature
Date
MM/DD/YYYY
Print Name
CC 0209 5/2021 Eff. 4/1/2021
License # 0B42994 - CaliforniaChoice Benefit Administrators
Inc.
Notice of Assistance Eligible Individuals
Group Name
Group #
Employee Name
Last 4 Digits of SSN
Last Day of Coverage
(MM/DD/YYYY)
Additional entries, if needed, can be entered on next page.
COBRA (Federal) AEIs
My signature below indicates I have verified the member(s) listed are AEIs that have opted-in for the COBRA subsidy. As an authorized group contact, I understand
COBRA premiums will be added to the group’s invoice, and the group will be responsible for the member’s COBRA premiums for up to 6 months from April 1, 2021
to the end of their COBRA eligibility period or they become eligible for other group health coverage or Medicare.
Complete the table below listing all Assistance Eligible Individuals who have opted-in for the COBRA subsidy.
Assistance
Eligible Individuals are defined as all COBRA/Cal-COBRA qualified participants (and their families) who have been involuntarily terminated by their
employer (other than by reason of such employee’s gross misconduct) or have had the employee’s hours reduced to a level below health benefit eligibility, between
November 1, 2019 and August 31, 2021, and who have elected COBRA continuation coverage (including those who elect during the 2nd Special COBRA Election
period). Individuals who have voluntarily terminated their own employment are not considered AEIs.
Individuals who have been involuntarily terminated by their employer (other than by reason of such employee’s gross misconduct) or have had the employee’s hours
reduced to a level below health benefit eligibility, between November 1, 2019 and August 31, 2021, but do not have COBRA continuation coverage in effect as of
April 1, 2021, but who would be an Assistance Eligible Individual if such election were so in effect, or who elected COBRA continuation coverage and discontinued
from such coverage before April 1, 2021, must be notified by May 31, 2021, of their right to elect COBRA continuation coverage. This special election is an
extension of the original election period but does not extend the original COBRA eligibility period.
A completed Employee Termination Notification form is required for any employees that have terminated employment but continue to appear active on your group’s
invoice.
to: COBRA-ARPA@calchoice.com
or fax to (714) 908-3549
Submit this form to CaliforniaChoice no later than June 14, 2021
via email
27167
