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• COBRA General Notice

• If qualified beneficiaries elect COBRA continuation coverage, must the qualified beneficiaries pay for COBRA continuation coverage?*
  • Must pay
  • Aren’t required to pay
  A qualified beneficiary is an employee, an employee’s spouse, or an employee’s dependent child who is covered by an employer-sponsored group health plan on the day before a qualifying event.
• Does your plan provide retiree health coverage?*
  • Yes
  • No
• When must the employee notify the plan administrator of the following qualifying events: Divorce of the employee and spouse, legal separation of the employee and spouse, or a dependent child losing eligibility for coverage as a dependent child?*
  • 60 days
  • Other
• Other:*
• If applicable, explain any additional plan procedures an employee must follow to notify the plan administrator of the following COBRA qualifying events: Divorce of the employee and spouse, legal separation of the employee and spouse, or a dependent child losing eligibility for coverage as a dependent child.(optional)
  For example, describe any required information or documentation.
• Spanish version:(optional)
  The answer in this text area will merge into the Spanish version of this notice..
• If applicable, explain any additional plan procedures an employee must follow to notify the plan administrator of a request for a disability extension of his/her COBRA coverage. (optional)
  For example, describe any required information or documentation, the name of the appropriate party to whom notice must be sent, and the time period for giving notice.
• Spanish version:(optional)
  The answer in this text area will merge into the Spanish version of this notice..

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• Health Insurance Exchange Notice (for companies who offer a health plan)

• Is your health plan offered to all employees or just some employees?*
  • All employees
  • Some employees. Eligible employees are:
• *
  Explain the employee eligibility requirements under the group health plan.
• Does your health plan offer coverage to dependents?*
  • We do not offer coverage.
  • We do offer coverage. Eligible dependents are:
• *
  Explain the dependent eligibility requirements under the group health plan.
• Does your group health plan satisfy the minimum value and affordability standards of the Affordable Care Act?*
  • Yes
  • No

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• Medicare Part D Creditable Coverage Notice

• Does your health plan offer prescription drug coverage to Medicare-eligible individuals (in general, people age 65 or older, younger people with disabilities, or people with End Stage Renal Disease [permanent kidney failure requiring dialysis or transplant])?*
  • Yes
  • No
• Does your health plan provide Medicare Part D creditable coverage?*
  • Yes
  • No
• If you have both creditable and non creditable coverage, please add details here:
• Is this an Employer/Union sponsored group plan?*
  • Yes
  • No
• Was the previous employer-sponsored coverage creditable coverage under Medicare Part D?*
  • Yes
  • No
• If the participant decides to join a Medicare drug plan, will his or her current prescription drug coverage under your group health plan be affected?*
  • Yes
  • No
• Will the plan participant and his/her dependents be able to get prescription drug coverage back under your group health plan if they decide to enroll in Medicare Part D prescription drug coverage and drop their current prescription drug coverage under your group health plan?*
  • Yes
  • No
• Insert a sentence explaining the prescription drug coverage plan provisions/options under your group health plan that Medicare-eligible individuals have available to them when they become eligible for Medicare Part D:*

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• Mental Health Parity and Addiction Equity Act (MHPAEA) Disclosure

• Does your health plan offer medical/surgical benefits AND mental health or substance use disorder benefits?*
  • Yes
  • No

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• Michelle's Law Notice

• Does your health plan provide dependent coverage beyond age of 26?*
  • Yes
  • No
• Does your health plan require a certification of student status before providing dependent coverage beyond age 26?*
  • Yes
  • No
• Enter any other permissible eligibility conditions a plan participant must satisfy to be eligible to continue coverage upon a medically necessary leave of absence from school in the box below.
  Example: Student must be enrolled in the plan immediately prior to the first day of the medically necessary leave of absence.

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• Newborns’ and Mothers’ Health Protection Act Notice

• Does your health plan provide maternity or newborn infant coverage?*
  • Yes
  • No
• Enter any additional information regarding maternity or newborn infant coverage required by state law: (optional)

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• No Surprise Billing

• Emergency services – Explain any applicable state balance billing laws or requirements (in easy to understand language), including the applicable state agency website that can be visited for more information.
• Services at in-network hospital or ambulatory surgical center – Explain any applicable state balance billing laws or requirements (in easy to understand language), including the applicable state agency website that can be visited for more information.

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• Notice of Patient Protections

• Does your group health plan require or allow for the designation of primary care providers by participants or beneficiaries?*
  • No
  • Yes
• Your group health plan:*
  • Requires the designation of a primary care provider
  • Allows for the designation of a primary care provider
• Does your group health plan designate a primary care provider automatically?*
  • Yes
  • No
• Does your group health plan require or allow for the designation of a primary care provider for a child?*
  • Yes
  • No
• Does your group health plan provide coverage for obstetric or gynecological care (OB/GYN care) and require the designation by a participant or beneficiary of a primary care provider?*
  • Yes
  • No

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• Notice of Privacy Practices

• Does your health plan create or receive protected health information?*
  • Yes
  • No
• Select an effective date for your Notice of Privacy Practices*
• The federal HIPAA Privacy Rule requires covered entities to describe any state or other laws that require greater limits on disclosures. Insert this type of information below. If no laws with greater limits apply to your health plan, no information needs to be added. For further assistance, contact the U.S. Department of Health and Human Services’ Office of Civil Rights at 1-800-368-1019.*
• Spanish version:(optional)
  The answer in this text area will merge into the Spanish version of this notice..

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• Special Enrollment Rights Notice

• If the employee and/or his/her dependents lose eligibility for coverage under another health plan, or if the employer contributions toward that coverage cease, within how many days after that coverage ends must the employee request to enroll him/herself and/or his/her dependents in your group health plan?*
  • 30 days
  • Other:
• Other:*
• If the employee gains a new dependent as a result of marriage, birth, adoption, or placement for adoption, within how many days must the employee request to enroll him/herself and/or his/her dependents in your group health plan?*
  • 30 days
  • Other:
• Other:*

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• Summary of Material Modifications Or No Material Modifications

• Have you made a material reduction in covered services or benefits to your health plan within the last 60 days?
  • Yes
  • No
• Date material reduction made:
• Date material reduction effective:
• Services or benefits materially reduced:
  • Select All
  • Medical plan
  • Adoption assistance
  • Dental plan
  • Dependent care reimbursement account (DCRA) plan
  • Health flexible spending arrangement (FSA)
  • Health reimbursement arrangement (HRA)
  • Health savings account (HSA)
  • Life insurance plan
  • Long-term disability plan
  • Prescription drug plan
  • Short-term disability plan
  • Vision plan
  • Premium Conversion Plan / Pre-tax contributions
• Other not listed:
• Explain all of the material reductions in covered services or benefits made to the health plan:
• Have you made a material modification to your health plan that did not result in a material reduction in covered services or benefits?
  • Yes
  • No
• Date material modification made:
• Date material modification effective:

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• WHCRA Notice

• Does your health plan provide coverage for medical and surgical benefits related to a mastectomy?*
  • Yes
  • No
• In-network deductible/coinsurance amount applicable to mastectomy benefits:*
  Please provide the In-Network deductible and coinsurance amounts applicable to mastectomy benefits, along with the plan name if multiple plans are available.
• Is an out-of-network deductible amount and coinsurance percentage applicable to mastectomy benefits?*
  • Yes
  • No
• Out-of-network deductible/coinsurance amount applicable to mastectomy benefits:*
  Please provide the Out-of-Network deductible and coinsurance amounts applicable to mastectomy benefits, along with the plan name if multiple plans are available.
• List If there are additional Health Plans that provide coverage for medical and surgical benefits related to a mastectomy (provide both in and out of network related deductibles and co-insurance for each plan.

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• DELIVERY INSTRUCTIONS

• Deliverables sent to
  • Client Contact
  • Broker Contact
  • Both
• List names and emails of all client and broker contacts for delivery of documents:

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• Authorized Signer

• Name
  First Last
• Email
• Signature
  Your Name

  • Your Name
  • Your Name
  • Your Name

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• Billing & Submit App

• Payment Method*
  • Online Payment Center
  • Credit Card
  • Broker Paid
• 
  

• An invoice will be emailed to the billing contact within 3 business days.

• 
  
• Credit Card
  American Express

  Discover

  MasterCard

  Visa

  Supported Credit Cards: American Express, Discover, MasterCard, Visa

  Card Number Month010203040506070809101112 Year20262027202820292030203120322033203420352036203720382039204020412042204320442045 Expiration Date   Security Code Cardholder Name
• Coupon
  
• ERISA Plan Document & Health Notices
  Price:
• Total
  $0.00
• 
  
• Billing Contact Name*
  First Last
• Billing Contact Email*
• Billing Address
  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
• Billing Contact Phone
• 
  
  

• When you’re ready, click Submit to finish your application.

• 
  

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