COBRA Implementation Kit

1Company Information

2Billing Information

3Broker/ Agent Contact(s)

4Admin Provisions

5Medical Plan

6Dental Plan

7Vision Plan

8EAP

9Medical FSA

10HRA

11Optional Services

12Required Forms/Data

13Upload Files

14Renewal

15Client Acknowledgements & Signature

COMPANY INFORMATION
Is This An Employee Navigator Group?*
- No
- Yes, Admin America will pull the medical, dental, & vision plan(s)and rate(s) information directly from Emplooyee Navigator
- Yes, but prefer to provide the medical, dental, & vision plan(s) and rate(s) information on this application
For Employee Navigator groups, please ensure that Admin America is added as the COBRA vendor. Once we receive notice, we will pull plans and rates to began the integration process.
Is This The First Year That The Company Is Offering Health Benefits?*
- No
- Yes
Legal Company Name*
DBA
Employer Tax ID Number*
Employer Entity
Employer Size
Employees Covered
Company Phone#*
Physical Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address
Same as previous

Street Address Address Line 2 City State ZIP Code
Primary Contact*
First Last
Primary Title
Primary Email*
Enter Email Confirm Email
Primary Phone
Is There A Secondary Employer Contact?
Secondary Employer Contact*
First Last
Secondary Title
Secondary Email*
Enter Email Confirm Email
Secondary Phone
Are There Additional Employer Contacts?
Additional Employer Contacts
Contact Name Contact Phone# Contact Email
Contact Name Contact Phone# Contact Email

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BILLING INFORMATION
Billing information for admin fees
COBRA Admin America Services Effective Date

mm/dd/yy
Broker Billed
- Broker Billed
Broker Address
Street Address Address Line 2 City State ZIP Code
Broker Billing Contact
First Last
Invoicing of Admin Fees
Broker Billing Email
Enter Email Confirm Email

Invoicing of Admin Fees
Employer Billing Contact Is Same As:*
- Other - Complete Employer Billing Contact Information Below
- Primary Employer Contact
- Secondary Employer Contact
Employer Billing Contact*
First Last
Invoicing of Admin Fees
Employer Billing Email*
Enter Email Confirm Email

Invoicing of Admin Fees
Employer Billing Telephone
Invoicing of Admin America
Are There Additional Employer Billing Contacts?
Additional Employer Billing Contacts
Contact Name Contact Phone# Contact Email
Additional Employer Billing Contacts
Contact Name Contact Phone# Contact Email
Method of Payment for Admin Fees*
- ACH (AA debits the Company's bank account) - fill out the AA ACH Authorization Form.
- Credit Card (Once invoice is emailed to billing contact(s), a link to our online payment system will be available)
- Company sends AA Payment via ACH.
- Company mails check to AA each billing cycle
*For minimum sized groups we will bill on an annual basis. Otherwise, we will bill monthly.

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BROKER / AGENT CONTACT INFORMATION
Agent/Broker
Agent Company*
Agency Tax ID Number
Agent Physical Address*
Street Address Address Line 2 City State ZIP Code
Broker/Agent Name
First Last
Broker/Agent Email
Account Rep(s)*
First and Last Name Email Address Phone Number

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OTHER PLAN SERVICES AND ACKNOWLEDGEMENTS
Plan Rates Start Date*

mm/dd/yy
Plan Rates End Date*

mm/dd/yy
GENERAL RIGHTS NOTIFICATION
The Initical Notice or "General Rights Notice" is a document required by COBRA law to be sent to all new plan participants and covered dependents. The General Notice informs the plan participants and their dependents of their obligations should they experience a Qualifying Event. Willful failure to properly send this notice is subject to penalties and must be self-reported on IRS Form 8928. In addition, should an individual file suit against the employer for a perceived COBRA violation, the General Notice is often used as legal defense for the employer.
Have all of the employees whom are benefit eligible received an Initial Notice?*
If No, Elect Fee*
A Fee of $3.00 will be charged for each letter to a participant enrolled PRIOR to the Admin America COBRA Services Effective Date
Consent*
I agree to the $3.00 per Initial Notice fee.
ONGOING CARRIER NOTIFICATION SERVICE OPTIONS AND ACKNOWLEDGEMENTS
Authorize the level of service you are electing.*
STANDARD CARRIER NOTIFICATION SERVICES: - COBRA Participant Reinstatements - Admin America notifies the appropriate insurance carriers of the need to reinstate-enroll COBRA participants following receipt of their COBRA Election Form and receipt of their Initial Premium Payment. *Please note: Admin America does not terminate coverage with Carriers. BROKER NOTIFICATION SERVICE: - COBRA Participant Reinstatements and Terms. - Admin America notifies the appropriate broker of the need to reinstate-enroll and terminate COBRA participants. The broker will initiate the appropriate activity with the carrier(s) upon notification.
DISABILITY EXTENSION FEE
If a COBRA Participant is deemed disabled by the Social Security Administration, they may be eligible to remain on COBRA up to 29 months. If a COBRA participant chooses to extend their COBRA past their regular COBRA period, Employers have the option of increasing the standard 2% COBRA fee to 50% (Admin America retains 2%, the employer would receive the difference)
In the event of a participant accepting the Disability Extension, what fee would the Employer want the participant to pay?
GOHEALTH
Would you like to participate in GoHealth?
Admin America has partnered with GoHealth to offer alternative individual insurance coverage options to COBRA Qualified Beneficiaries. GoHealth is a private exchange solution that provides Qualified Beneficiaries with access to online decision support tools as well as telephone guidance from licensed insurance support tools as well as telephone guidance from licensed insurance advisors. GoHealth also offers Qualified Beneficiaries information about coverage and subsidies available through the public ACA Marketplace in their state. Admin America does not want to compete with any similar efforts that your insurance agent/broker may be utilizing to offer alternative insurance coverage to your COBRA Qualified Beneficiaries. If you would prefer that Admin America NOT offer this service, please select No.

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MEDICAL PLAN INFORMATION
Does Employer Offer Group Medical?*
Are There Multiple Employer Divisions?
- No
- Yes
Division Name*
Division 1 Division 2 Division 3 Division 4
Enrollment Carrier Email(s)*
Coverage will end for Qualified Beneficiaries*
Medical Plan Rates Start Date*

mm/dd/yy
Medical Plan Rates End Date*

mm/dd/yy
Check To Upload Medical Age Banded Rates
- Upload Age Banded Rates
1 Medical Plan*
Insurance Carrier Medical Plan Name
1 Medical Plan
Medical Group# Employer Division (if applicable)
1 Medical Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more
2 Medical Plan
Insurance Carrier Medical Plan Name
2 Medical Plan
Medical Group# Employer Division (if applicable)
2 Medical Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)
EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more
3 Medical Plan
Insurance Carrier Medical Plan Name
3 Medical Plan
Medical Group# Employer Division (if applicable)
3 Medical Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)
EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more
4 Medical Plan
Medical Plan Name Medical Group# Employer Division (if applicable)
4 Medical Plan
Insurance Carrier Medical Plan Name
4 Medical Plan
Medical Group# Employer Division (if applicable)
4 Medical Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)
EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more
Upload Age Banded Medical Rate Sheet
Drop files here or

Max. file size: 100 MB, Max. files: 3.

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DENTAL PLAN INFORMATION
Does Employer Offer Group Dental?*
Dental Plan Information*
Carrier Name Group Account#
Enrollment Carrier Email*
Enrollment Carrier Email
Coverage will end for Qualified Beneficiaries*
Dental Plan Rates Start Date*

mm/dd/yy
Dental Plan Rates End Date*

mm/dd/yy
Check To Upload Dental Age Banded Rates
- Upload Age Banded Rates
1 Dental Plan Name
1 Dental Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more
2 Dental Plan Name
2 Dental Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)
EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more
3 Dental Plan Name
3 Dental Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)
EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more
4 Dental Plan Name
4 Dental Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)
EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more
Upload Age Banded Dental Rate Sheet
Drop files here or

Max. file size: 100 MB, Max. files: 3.

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VISION PLAN INFORMATION
Does Employer Offer Group Vision?*
Vision Plan Information*
Carrier Name Group Account Number
Enrollment Carrier Email*
Vision Plan Rates Start Date*

mm/dd/yy
Vision Plan Rates End Date*

mm/dd/yy
Coverage will end for Qualified Beneficiaries*
Check To Upload Vision Age Banded Rates
- Upload Age Banded Rates
1 Vison Plan Name
1 Vision Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more
2 Vison Plan Name
2 Vision Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)
EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more
3 Vison Plan Name
3 Vision Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)
EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more
4 Vison Plan Name
4 Vision Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)
EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more
Upload Age Banded Rate Sheet
Drop files here or

Max. file size: 100 MB, Max. files: 3.

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COBRA ELIGIBLE EAP PLAN INFORMATION
Does Employer Offer a COBRA Eligible EAP Plan?*
*
Carrier Name Group / Account Number Enrollment Carrier Email
Coverage will end for Qualified Beneficiaries*
Monthly Composite Rates (Do Not Include 2% COBRA Administrative Fee)*
Plan Name EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more

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MEDICAL FSA PLAN INFORMATION
Does Employer Offer an FSA Plan?*
Is the FSA Plan Administered by Admin America?*
*
Plan Administrator Administrator Contact
FSA Contact/Team Email*
Enter Email Confirm Email
FSA Administrator Telephone
FSA Plan Year*
Plan Year Start Date Plan Year End Date

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HRA PLAN INFORMATION
Does Employer Offer an HRA Plan?
Is the HRA Plan Administered by Admin America?*
*
Plan Administrator Administrator Contact
HRA Contact Team Email*
Enter Email Confirm Email
HRA Administrator Telephone
HRA Plan Year*
Plan Year Start Date Plan Year End Date
Bundled Enrollment or Ability to Opt-Out Enrollment?*
Option 1 : Opt-Out (Recommended): Member may choose to Opt-Out of HRA Benefits. Option 2: Bundled Enrollment: Member cannot Opt-Out of the HRA when enrolled in Medical Plan.
Would you like for Admin America to calculate the HRA rates?*
- No
- Yes
Unless there are prior years claim utilization information, we will use 30% of the annual benefit.
1 HRA Monthly COBRA Premiums (Do Not Include 2% COBRA Administrative Fee)
Plan Name EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more
2 HRA Monthly COBRA Premiums (Do Not Include 2% COBRA Administrative Fee)
Plan Name EE Only EE & Spouse EE & Child Family EE + 1 EE + 2 or more

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ADDITIONAL OPTIONAL SERVICES
Additional fees may apply.
COBRA Specific Rights Notice Letter*
- Accept Charges
- Do Not Accept Charges
If Recently Terminated Employees (RTE) terminated prior to Admin America taking over administration and they have not received their initial Specific Rights Notice Letter, there will be a $20.00 charge for Admin America to send out the inotice.
Consent
I agree to the additional charges.
EDI Feed
- No
- Yes
Accept EDI Fees*
- Decline EDI Option
- COBRA QE/NPM Eligibility Files - $250
Consent*
I agree to the EDI Fees
EDI Vendor Name

EDI Vendor Contact will need to send an email to edi@adminamerica.com to begin the integration process.
Note Below Any Additional Information That We Should Be Aware Of

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REQUIRED FORMS AND DATA
Click Here to Access the COBRA Takeover Authorization Form The Secure Link to Upload is Located in the Following Section Titled, "Upload Files". *Reminder Send directly to the insurance carriers. You may also provide Admin America a copy for our records. Please note some insurance carriers require their own form to be completed. Please check with them.
Click Here to Access the Admin Fees ACH Auth Form The Secure Link to Upload is Located in the Following Section Titled, "Upload Files".
Click Here to Access the COBRA Census The Secure Link to Upload is Located in the Following Section Titled, "Upload Files".
-The first tab is for all the currently active employees enrolled in a cobra eligible benefit;

-The second tab is for all currently enrolled COBRA participants and any in the waiting period to elect

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UPLOADS
Upload All Required Forms and Data
Click Here to Upload Files Securely

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Click Here to Access the Renewal Kit
Click Here to Access the Renewal Kit
Click Here to Access the Renewal Census
Click Here to Upload Renewal Information *Please Add the Name of the Company on Census for Identification

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CLIENT SIGNATURE
Please complete the form and rates carefully. Any changes that cause Admin America Inc. to reprocess notifications to Qualified Beneficiaries and/or COBRA participants will result in a $20.00/per participant reprocessing fee.

By entering your name below you are electronically signing this form.

I understand the participant reprocessing fee stating above. The information I have supplied herein is accurate and should be used by Admin America Inc. for COBRA rates as of the date in which Admin America takes over.

Your Name*

Email*

Date*
MM slash DD slash YYYY

Untitled

Untitled

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Questions

8:30 am – 5:00 pm EST

Admin America, Inc.

770-992-5959 800-366-2961

COBRA Implementation Kit

COMPANY INFORMATION

BILLING INFORMATION

BROKER / AGENT CONTACT INFORMATION

OTHER PLAN SERVICES AND ACKNOWLEDGEMENTS

GENERAL RIGHTS NOTIFICATION

ONGOING CARRIER NOTIFICATION SERVICE OPTIONS AND ACKNOWLEDGEMENTS

DISABILITY EXTENSION FEE

GOHEALTH

MEDICAL PLAN INFORMATION

DENTAL PLAN INFORMATION

VISION PLAN INFORMATION

COBRA ELIGIBLE EAP PLAN INFORMATION

MEDICAL FSA PLAN INFORMATION

HRA PLAN INFORMATION

ADDITIONAL OPTIONAL SERVICES

REQUIRED FORMS AND DATA

UPLOADS

CLIENT SIGNATURE

Contact Name	Contact Phone#	Contact Email

Contact Name	Contact Phone#	Contact Email

Contact Name	Contact Phone#	Contact Email

Contact Name	Contact Phone#	Contact Email