COBRA Implementation Kit

1Company Information

2Billing Information

3Broker/ Agent Contact(s)

4Admin Provisions

5Carrier Enrollment Contact Information

6Medical Plan

7Dental Plan

8Vision Plan

9EAP

10Medical FSA

11HRA

12Optional Services

13Form Downloads

15Acknowledgement & Signature

COMPANY INFORMATION
Applicant Relationship
- Broker Contact
- Client Contact
Who is completing this application
Should we include the client contact in our communications requesting further information for the implementation phase?
- No
- Yes
Is This An Employee Navigator Group?*
- No
- Yes
- Yes, but prefer to provide the plan(s) and rate(s) information on this application
If your Benefit Enrollment System is Employee Navigator, please ensure that Admin America is added as the COBRA vendor.
Will Admin America be added as the COBRA vendor in Employee Navigator within the next 5-7 business days?*

No

Yes
Once we receive notice that Admin America has been added as the COBRA vendor in Employee Navigator, 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

Company initiated 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.
Click Here to download the ACH Form for Admin Fees

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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

Broker Account Manager*
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.
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?
Authorize the level of service you are electing.*
COBRA PARTICIPANT REINSTATEMENT OPTIONS:

Standard Notification Service:
Admin America notifies the appropriate insurance carriers of the need to reinstate-enroll coverage for COBRA participants following receipt of their COBRA Election Form and Initial Premium Payment.

Broker Notification Service:
Admin America notifies the appropriate broker contact of the need to reinstate-enroll and terminate COBRA participants. The broker will initiate the appropriate activity with the carrier(s) upon notification.

*Please note: Admin America does not terminate coverage with Carriers.
Hidden
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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REINSTATEMENT OPTIONS (COBRA ENROLLMENTS CONTACT)
CARRIER ENROLLMENT CONTACTS
Carrier Enrollment Contacts would be the enrollment individual contact or team E-Mail address and phone numbers where Admin America would send coverage reinstatements to.
Medical Carrier Enrollment Contact Name or Team Name:

Medical Carrier Enrollment Contact Email:

Medical Carrier Enrollment Phone #
Dental Carrier Enrollment Contact Name or Team Name:

Dental Carrier Enrollment Contact Email:

Dental Carrier Enrollment Phone #
Vision Carrier Enrollment Contact Name or Team Name:

Vision Carrier Enrollment Contact Email:

Vision Carrier Enrollment Phone #

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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

Is Medical Plan Fully Insured or Self Insured
Does Medical Carrier require monthly paid thru date reports?
Medical carrier enrollment contact*

The name of the insurance carrier individual or team email that reinstatements would go to.
Medical carrier enrollment contact email (DO NOT enter the broker contact here)*

*VERY IMPORTANT to have accurate contact information- This would be the email for the contact to send reinstatement of coverage requests.
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: 8 MB, Max. files: 3.

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DENTAL PLAN INFORMATION
Does Employer Offer Group Dental?*
Is Dental Plan Fully Insured or Self Insured
Does Dental Carrier require monthly paid thru date reports?
Dental carrier enrollment contact*

The name of the invididual or team email that reinstatements would go to.
Dental carrier enrollment contact email (DO NOT enter the broker contact here)*

*VERY IMPORTANT to have accurate contact information- This would be the email for the contact to send reinstatement of coverage requests.

Dental Plan Information*
Carrier Name Group Account#

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: 8 MB, Max. files: 3.

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VISION PLAN INFORMATION
Does Employer Offer Group Vision?*
Is Vision Plan Fully Insured or Self Insured
Does Vision Carrier require monthly paid thru date reports?
Vision carrier enrollment contact*

The name of the invididual or team email that reinstatements would go to.

Vision carrier enrollment contact email (DO NOT enter the broker contact here)*

*VERY IMPORTANT to have accurate contact information- This would be the email for the contact to send reinstatement of coverage requests.
Vision Plan Information*
Carrier Name Group Account Number

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: 8 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 Carrier enrollment contact 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

Does FSA Administrator require monthly paid thru date reports?

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HRA PLAN INFORMATION
Does Employer Offer an HRA Plan?
Is the HRA Plan Administered by Admin America?*
*
Plan Administrator

HRA Contact Team Email*
Enter Email Confirm Email

HRA Administrator Telephone
HRA Plan Year*
Plan Year Start Date Plan Year End Date

Does HRA Administrator require monthly paid thru date reports?
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. for Deductible only HRAs and 60% of the annual benefit for all other HRAs.
1 HRA Monthly COBRA Premiums (Do Not Include 2% COBRA Administrative Fee)*
Plan Name EE Only EE & Spouse EE & Child Family

2 HRA Monthly COBRA Premiums (Do Not Include 2% COBRA Administrative Fee)*
Plan Name EE Only EE & Spouse EE & Child Family

Type of HRA*

Deductible Only Reimbursement

Other
HRA Benefit - How much does the HRA pay out in total*
EE Only EE & Spouse EE & Child Family

How much does the HRA pay out in total
HRA Benefit - How much does the HRA pay out in total*
EE Only EE & Spouse EE & Child Family

How much does the HRA pay out in total
Would you like for prior year HRA utilization % to be considered in the rate calculation?

No

Yes
A utilization report for the final year will need to be provided.
Upload prior year utilization report*
Max. file size: 8 MB.

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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 COBRA Continuation Coverage Election Notice, there will be a $10.00 charge per notice that Admin America sends.
Consent*
I agree to the additional charges.
If Recently Terminated Employees (RTE) terminated prior to Admin America taking over administration and they have not received their initial COBRA Continuation Coverage Election Notice, there will be a $10.00 charge per notice that Admin America sends.

EDI Feed

No

Yes
Accept EDI Fees*

Decline EDI Option

COBRA QE/NPM Eligibility Files - $250
Consent*
I agree to the EDI Fees
I Agree to the EDI Fee
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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FORM DOWNLOADS
Click Here to download the ACH Form for Admin Fees
Click Here to download the Active Employee & COBRA Member Census Template

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Click Here to download the ACH Form for Admin Fees
Click Here to download the Active Employee & COBRA Member Census
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
Applicant First Name*
First
Applicant Last Name*
Last
Applicant Email*
Enter Email Confirm Email

Applicant will receive a copy of the completed application
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

Signature*
CAPTCHA

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Questions

8:30 am – 5:00 pm EDT

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

DISABILITY EXTENSION FEE

REINSTATEMENT OPTIONS (COBRA ENROLLMENTS CONTACT)

CARRIER ENROLLMENT CONTACTS

MEDICAL PLAN INFORMATION

DENTAL PLAN INFORMATION

VISION PLAN INFORMATION

COBRA ELIGIBLE EAP PLAN INFORMATION

MEDICAL FSA PLAN INFORMATION

HRA PLAN INFORMATION

ADDITIONAL OPTIONAL SERVICES

FORM DOWNLOADS

CLIENT SIGNATURE