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Request For Treatment As An Assistance Eligible Individual Form


Request For Treatment As An Assistance Eligible Individual Form

 
Request For Treatment As An Assistance Eligible Individual Form
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The 1986 Consolidated Omnibus Budget Reconciliation Act (COBRA) extends group health care coverage for employees and other beneficiaries that have involuntarily lost their employment or had a reduction in the number of hours that they work. COBRA allows qualifying individuals to continue to receive group health care coverage at a group rate for a limited period of time.

There have been significant changes to COBRA with the American Recovery and Reinvestment Act of 2009 (Stimulus Plan). These changes have extended coverage to some individuals that may not have previously elected to participate in COBRA. They have also made it possible for individuals to received reduced rates on their COBRA premiums.

Individuals may request to receive COBRA premium reduction assistance when they enroll in COBRA. In order to do so, they should complete the Request for Treatment as an Assistance Eligible Individual form and submit it along with their COBRA Election form.

Who Qualifies as an Assistance Eligible Individual

The American Recovery and Reinvestment Act of 2009 (Stimulus Plan) helps to reduce premium rates for individuals enrolled in COBRA programs. However, if an individual is eligible to receive health care coverage through another group health care coverage plan or through Medicare, the individual will not qualify for the assistance.
In order to receive assistance, the individual must meet the following requirements:
  • The participant must have been (or be) eligible for COBRA coverage from September 1, 2008 to December 31, 2009.
  • In participant needs to have elected to participate in COBRA

Individuals should also be aware that by electing to have assistance, the individual will be disqualified from the Health Coverage Tax Credit

Potential COBRA beneficiaries include

  • Former employees
  • Retirees
  • Spouses of former employees or retirees
  • Former spouses of former employees and retirees
  • Former spouses of employees and retirees
  • Dependent children

Product Specifications:

  • This for is 8.5" x 11"
  • 50 sheets/pkg

 
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