DentalandVisionIns.com
Federal COBRA or CAL COBRA

Please use this page to communicate which COBRA regulations your group is subject to for a calendar year.

A group is subject to Federal COBRA regulations if they had 20 or more employees on more than 50 percent of its typical business days in the previous calendar year. Both full and part-time employees are counted to determine whether a plan is subject to COBRA. Each part-time employee counts as a fraction of an employee, with the fraction equal to the number of hours that the part-time employee worked divided by the hours an employee must work to be considered full-time.

Groups of 2 to 19 are subject to Cal-COBRA regulations. 

This may change every year. 
You will need to report a change in your status.

For Federal COBRA groups, please make sure you give the member the COBRA information upon termination.  When they wish to continue coverage you will need to set up premium collection with them and report the member to us as continuing under COBRA.  We will reinstate their coverage on your group invoice.  COBRA election forms can be found at the following link, forms.

For Cal-COBRA groups you will need to give us the terminating member's home address with the termination and we will send a COBRA election form. Once we receive a response we will set up individual premium collection directly with the member.

For more information on the Federal COBRA regulations,
please follow this link to the Department of Labor web site.

For questions on Cal-COBRA, follow this link to the California Department of Insurance web site.

Please indicate your response in the form below.
Please provide the following information.
Your Name:  
Your E-mail address: 
This form will not be processed without your e-mail address. 
Your E-mail address will only be used if we have questions on the requested action

Name of Group Client that this information is being submitted for:
  

Enter the Client ID:
Example: 123456-0.  The Client ID # is located on the invoice.


Please indicate which COBRA regulations your group is subject to:
 Cal-COBRA
 Federal COBRA 
 
Enter the year for which this applies.
 

 

Please check the box to indicate that your group uses a COBRA administrator that will be handling all your COBRA responsibilities.

We use a COBRA administrator.
With a COBRA administrator we would be notified when a member continues coverage.  The premium collection is done by a third party under contract with your group.  The continuing member would show on your invoice from us and their premium would be forwarded to you by the COBRA administrator.


Please give us any additional information that you feel
may be necessary to process this information.
 
Last revised: December 01, 2009