Application for Expedited Review of Denial of COBRA Premium Reduction
*Individuals who lost coverage because of a qualifying event that was a reduction of hours that occurred any time from September 1, 2008 through May 31, 2010 may be eligible for the premium reduction if the employee is then involuntary terminated on or after March 2, 2010 and no later than May 31, 2010. The premium assistance for these individuals begins with the first period of coverage following the employee's termination (that occurs on or after March 2, 2010 through May 31, 2010). These individuals are also provided a new election opportunity if they did not elect (or elected and discontinued) COBRA. [A reduction of hours qualifying event occurs when the employee and his/her family lose coverage because the employee's hours were reduced or the employee is no longer working enough hours required by the plan to maintain the group health coverage although they are still employed.]
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.
If you believe you are eligible for COBRA continuation coverage and for this premium reduction through a private sector health plan sponsored by an employer generally with at least 20 employees, but your request for these benefits or the reduced premium has been denied, you may apply to the U.S. Department of Labor to review the denial. If your benefits were provided by the Federal government (under Temporary Continuation Coverage (TCC) of the FEHBP), a State or local governmental plan (such as a public school, a public college or university or a police or fire department), or if it is provided pursuant to State insurance law, you should direct your request for review to the Department of Health and Human Services or access their Web site at www.ContinuationCoverage.net.
Applying For Review: Answer all of the questions on the application to the best of your knowledge and ability. If you don't know the answer to a question you may check the box marked "Unsure or N/A." (N/A stands for "not applicable.") The red asterisk (*) denotes required information. Please include copies of any documents that you think would help the Department in its review of your application, examples of which are listed in the attached instructions. Provide your complete contact information (daytime phone number, an alternate phone number, and an email address, if available) so that the person reviewing your application can contact you with any questions or if additional information is needed. The Department of Labor will not review your denial until you submit a properly completed application form. A separate application(s) must be completed for any family member whose plan information is not identical to the information you provide. Keep a copy of the application(s) submitted for your records. Note: In the course of its review, the Department may need to share information on this application with your employer or plan administrator.
You are encouraged to complete your application online at www.dol.gov/COBRA or, you can fax or mail this completed application, along with your attachments, to:
For Assistance: If you have questions on how to complete this form or about eligibility for COBRA or the COBRA premium reduction, please see our Web site at www.dol.gov/COBRA. You may also call a DOL Benefits Advisor toll-free at 1-866-444-3272. Benefits Advisors can assist you with questions, but cannot complete or take your application for review by phone.