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Admin America, Inc.

Alpharetta, GA 30005

770-992-5959      Â  800-366-2961

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COBRA Implementation Kit

Home 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
13
14Acknowledgement & Signature
  • COMPANY INFORMATION

    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.
  • Contact NameContact Phone#Contact Email 
  • Contact NameContact Phone#Contact Email 
Save and Continue Later
  • BILLING INFORMATION

    Billing information for admin fees
  • mm/dd/yy
  • Invoicing of Admin Fees
  • Invoicing of Admin Fees
  • Invoicing of Admin Fees
  • Invoicing of Admin Fees
  • Invoicing of Admin America
  • Contact NameContact Phone#Contact Email 
  • Contact NameContact Phone#Contact Email 
    *For minimum sized groups we will bill on an annual basis. Otherwise, we will bill monthly.
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  • BROKER / AGENT CONTACT INFORMATION

  • First and Last NameEmail AddressPhone Number 
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  • OTHER PLAN SERVICES AND ACKNOWLEDGEMENTS

  • mm/dd/yy
  • 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.
  • A Fee of $3.00 will be charged for each letter to a participant enrolled PRIOR to the Admin America COBRA Services Effective Date
  • ONGOING CARRIER NOTIFICATION SERVICE OPTIONS AND ACKNOWLEDGEMENTS

  • 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)
  • Hidden
    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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  • 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.
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  • MEDICAL PLAN INFORMATION

  • Division 1Division 2Division 3Division 4 
  • The name of the invididual or team email that reinstatements would go to.

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

  • mm/dd/yy
  • mm/dd/yy
  • Insurance CarrierMedical Plan Name 
  • Medical Group#Employer Division (if applicable) 
  • EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more 
  • Insurance CarrierMedical Plan Name 
  • Medical Group#Employer Division (if applicable) 
  • EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more
  • Insurance CarrierMedical Plan Name 
  • Medical Group#Employer Division (if applicable) 
  • EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more
  • Medical Plan NameMedical Group#Employer Division (if applicable) 
  • Insurance CarrierMedical Plan Name 
  • Medical Group#Employer Division (if applicable) 
  • EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more
  • Drop files here or
    Max. file size: 8 MB, Max. files: 3.
    Save and Continue Later
    • DENTAL PLAN INFORMATION

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

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

    • Carrier NameGroup Account# 
    • mm/dd/yy
    • mm/dd/yy
    • EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more
    • EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more
    • EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more
    • EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more
    • Drop files here or
      Max. file size: 8 MB, Max. files: 3.
      Save and Continue Later
      • VISION PLAN INFORMATION

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

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

      • Carrier NameGroup Account Number 
      • mm/dd/yy
      • mm/dd/yy
      • EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more
      • EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more
      • EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more
      • EE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more
      • Drop files here or
        Max. file size: 8 MB, Max. files: 3.
        Save and Continue Later
        • COBRA ELIGIBLE EAP PLAN INFORMATION

        • Carrier NameGroup / Account NumberEnrollment Carrier Email 
        • Plan NameEE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more 
        Save and Continue Later
        • MEDICAL FSA PLAN INFORMATION

        • Plan AdministratorAdministrator Contact 
        • Plan Year Start DatePlan Year End Date 
        Save and Continue Later
        • HRA PLAN INFORMATION

        • Plan AdministratorAdministrator Contact 
        • Plan Year Start DatePlan Year End Date 
        • 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.
          Unless there are prior years claim utilization information, we will use 30% of the annual benefit.
        • Plan NameEE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more 
        • Plan NameEE OnlyEE & SpouseEE & ChildFamilyEE + 1EE + 2 or more 
        Save and Continue Later
        • ADDITIONAL OPTIONAL SERVICES

          Additional fees may apply.
          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.
        • EDI Vendor Contact will need to send an email to edi@adminamerica.com to begin the integration process.
        Save and Continue Later
        • 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
        Save and Continue Later
        • 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.


        • MM slash DD slash YYYY
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