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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
13Form Downloads
14
15Acknowledgement & Signature
  • COMPANY INFORMATION

    Who is completing this application
    If your Benefit Enrollment System is Employee Navigator, please ensure that Admin America is added as the COBRA vendor.
    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.
  • Contact NameContact Phone#Contact Email 
  • Contact NameContact Phone#Contact Email 
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  • 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.
  • Click Here to download the ACH Form for Admin Fees
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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
  • 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)
  • 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
    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.
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  • MEDICAL PLAN INFORMATION

  • Division 1Division 2Division 3Division 4 
  • The name of the insurance carrier individual 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 NumberCarrier enrollment contact 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 Administrator 
        • 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. for Deductible only HRAs and 60% of the annual benefit for all other HRAs.
        • Plan NameEE OnlyEE & SpouseEE & ChildFamily 
        • Plan NameEE OnlyEE & SpouseEE & ChildFamily 
        • EE OnlyEE & SpouseEE & ChildFamily 
          How much does the HRA pay out in total
        • EE OnlyEE & SpouseEE & ChildFamily 
          How much does the HRA pay out in total
          A utilization report for the final year will need to be provided.
        • Max. file size: 8 MB.
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        • 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 COBRA Continuation Coverage Election Notice, there will be a $10.00 charge per notice that Admin America sends.
        • 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.

        • I Agree to the EDI Fee
        • EDI Vendor Contact will need to send an email to edi@adminamerica.com to begin the integration process.
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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
        Save and Continue Later
        • 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
        Save and Continue Later
        • CLIENT SIGNATURE

        • 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.


        • MM slash DD slash YYYY
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