Form EBSA 301 EBSA 301 Plan Sponsor/Plan Administrator Information Sheet

U . S. Department of Labor

Employee Benefits Security Administration

Washington, DC 20210

{Insert Date}

Plan Administrator

Re: Application for Expedited Review of Denial of COBRA Premium Reduction

Applicant’s name: [First Name] [Last Name]

Employee name: [First Name] [Last Name]

Control number: [Record number]

Dear Plan Administrator:

The American Recovery and Reinvestment Act of 2009 (ARRA) provides for premium assistance for health benefits under the Consolidated Omnibus Budget Reconciliation Act of 1985, commonly called COBRA. ARRA provides for premium assistance for health benefits under the Consolidated Omnibus Budget Reconciliation Act of 1985, commonly called COBRA. The premium assistance is also available for continuation coverage under certain State laws. For coverage periods beginning on or after February 17, 2009, assistance eligible individuals pay only 35% of their continuation coverage premiums to the plan for the first fifteen months. The remaining 65% is reimbursed to the plan, employer, or health insurance issuer through a payroll tax credit. The 2010 Defense Appropriations Act extended the eligibility period for the ARRA premium reduction from December 31, 2009 to February 28, 2010 and the maximum period for receiving the subsidy from nine to fifteen months.

To be eligible for assistance, an individual must meet the following requirements:

• Have a qualifying event for continuation coverage under COBRA or a State law that provides comparable continuation coverage (for example, so-called “mini-COBRA” laws) that is the employee’s involuntary termination during the period beginning September 1, 2008 and ending February 28, 2010; and

• Elect continuation coverage (within the applicable timeframes).

NOTE: The new law also provides that individuals who had reached the end of the reduced premium period before the legislation extended it to 15 months will have additional time to pay the reduced premiums related to the extension. To continue their coverage they must pay the 35% of premium costs by February 17, 2010 or, if later, 30 days after notice of the extension is provided by their plan administrator.

However, an individual is not eligible for premium assistance if the individual is eligible for coverage under any other group health plan or Medicare.

The applicant (person requesting review of a denial of premium assistance) may either be the former employee or a member of the employee’s family who is eligible for COBRA continuation coverage or the COBRA premium assistance through an employment-based health plan. The employee and his/her family members may each elect to continue health coverage under COBRA, request the premium assistance, and request a review of a denial of premium assistance.

We have received an application for expedited review from the individual named above who claims to have been denied premium reduction in connection with COBRA continuation coverage under your plan. In order to make a determination regarding this person’s eligibility for COBRA continuation coverage and the ARRA COBRA premium reduction, we need information from you regarding the individual’s coverage under the plan and the circumstances related to the job loss which gave rise to the COBRA eligibility. The ARRA statute requires the determination to be made within 15 business days of receipt of the individual's request; therefore, we ask that you complete the information below and return it to us within 2 business days. If we do not receive this information within that time period, the determination may have to be made solely on the basis of the information provided by the individual.

Please complete the attached form and submit it electronically by going to the COBRA page at www.dol.gov/COBRA and clicking on the first link under “For Employers”. You may also send us the information and any attachments using the attached Bar Code Cover page by fax or mail to:

Fax to: U.S. Department of Labor, EBSA Mail to: U.S. Department of Labor, EBSA

Attn: COBRA Appeals Attn: COBRA Appeals

Fax number: (202) 693-8849 (not toll-free) P.O. Box 78038

Washington, DC 20013-9038

Please put the Control number (above) on all correspondence. If you need assistance, please

call a COBRA appeals unit representative toll-free at (877) 522-7880.

Sincerely,

Cobra Appeals Processing Unit

Attachments

Plan Sponsor/Plan Administrator Information Sheet

OMB Control Number 1210-0135 Exp. Date: 11/30/2012

Applicant’s name: [First Name] [Last Name]

Employee name: [First Name] [Last Name]

Control number: [Record Number]

Date of employee’s job termination: _____/_____/_____

Date of termination of benefits: _____/_____/_____

Please indicate whether the applicant was denied COBRA continuation coverage or the ARRA

COBRA Premium Reduction and check the reason for the denial below:

 Not denied, the applicant has been provided with or will be provided with COBRA

continuation coverage and the ARRA COBRA premium reduction.

Please enter the date the applicant’s request was approved: _____/_____/_____

• Denied because the qualifying event was not the employee’s involuntary termination of employment. Please enter any pertinent details regarding the circumstances of the employee’s termination in the comment section below. (For help in determining what job loss situations are involuntary terminations, see IRS Guidance at www.dol.gov/COBRA.)

 Denied because the employee’s job loss did not occur during the period from September 1, 2008 through February 28, 2010.

 Denied because the applicant was not covered by the group health plan on the day before the qualifying event, and was not a new dependent (or dependents) by birth, adoption, or placement for adoption.

 Denied because the applicant did not elect COBRA continuation coverage (either at the first opportunity or under any Extended Election period).

 Denied because the employee was dismissed for gross misconduct. The applicant was / was not (circle one) offered COBRA continuation coverage. If claiming the employee was dismissed for gross misconduct, please provide detailed information regarding the alleged conduct in the comment section below and by attaching additional pages (such as termination paperwork, copies of investigations, etc.).

 Denied because the employer is exempt from COBRA under the small employer exemption (see information below).

The rules regarding whether an employer is exempt from COBRA under the small-employer exception can be complex. Generally, COBRA only applies to group health plans maintained by employers that have at least 20 employees on more than 50 percent of its typical business days in the previous calendar year. Both full- and part-time employees are counted to determine whether a plan is subject to COBRA. Each part-time employee counts as a fraction of a full-time employee, with the fraction equal to the number of hours that the part-time employee worked divided by the hours an employee must work to be considered full time.

If exempt under the small employer exception, is the plan fully insured and subject to state continuation coverage?  Yes  No Unsure

 Denied because the employer no longer sponsors a group health plan. Please check the box or enter the date as appropriate:

 The employer never sponsored a group health plan.

The employer sponsored a health plan, but it was terminated effective ____/____/_____

If you no longer sponsor a group health plan, is there another entity* that may be liable to provide COBRA continuation coverage to the participants and beneficiaries?

 Yes  No Unsure

If yes, please enter the name, address and contact information for that entity in the comment section below as well as a brief description of the circumstances that you believe makes them liable to provide COBRA continuation coverage.

*Please note: under special rules, if your company was acquired by another business that provides group health benefits, the acquiring business may have successor liability and a duty to offer COBRA continuation coverage to participants and beneficiaries. Additionally, all of COBRA’s requirements apply to employers on a “controlled group” basis as defined in the Internal Revenue Code. These rules may require employers in a "parent-subsidiary" or "brother-sister" relationship as measured by an ownership test to provide COBRA benefits. If you acquired or were acquired by another business, or your business is part of a control group, you may want contact EBSA toll free at 1-866-444-3272 to speak to a Benefits Advisor for assistance in determining whether you or another entity may need to provide COBRA continuation coverage.

 Denied for other reason(s), please explain:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Under penalty of perjury, I declare that the information completed above and any accompanying

attachments are true, correct and complete to the best of my knowledge and belief.

Signature: _____________________________________________Date:___________________________

Type or print name: _________________________________________________________________________

Address, if different from above: __________________________________________________________________________

Phone number: ______________________ Fax number: ____________________________

Paperwork Reduction Act Statement

A

EBSA 301

ccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 15 minutes per response, including time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefit (see section 3001(a)(5) of the American Recovery and Reinvestment Act, P.L. 111-5, as amended by the Department of Defense Appropriations Act, 2010, P.L. 111-118). Please send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Office of the Chief Information Officer, Attention: Departmental Clearance Officer, 200 Constitution Avenue, N.W., Room N-1301, Washington, DC 20210 and reference the OMB Control Number. Note: Please do not return the completed application to this address.