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DOL > EBSA > COBRA > Application for Review of Denial

Application For Expedited Review Of Denial
Of COBRA Premium Reduction

General Information: If you or a family member has lost employment, the American Recovery and Reinvestment Act of 2009 (ARRA) may make it possible for you to keep your employment-related health coverage. The Act 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 Department of Defense Appropriations Act, 2010 (2010 DOD Act) extended the eligibility period for the COBRA 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 considered an "Assistance Eligible Individual" and receive reduced premiums you:

  • MUST have a continuation coverage election opportunity related to an involuntary termination of employment that occurred at any time from September 1, 2008 through February 28, 2010;

  • MUST elect the coverage (within the appropriate timeframes);

  • MUST NOT be eligible for Medicare; AND

  • MUST NOT be eligible for coverage under any other group health plan, such as a plan sponsored by a successor employer or a spouse's employer.

NOTE: The 2010 DOD Act provides an extended period of time to make reduced payment for certain periods of coverage. If you have reached the end of the original reduced premium period and have additional months of continuation coverage available, you can make a retroactive payment of the reduced premium(s) for the period(s) of coverage immediately following what would have been the last period subject to the premium reduction. This payment must be made by the later of February 17, 2010, 30 days from the date this notice was provided to you, or the end of the otherwise applicable payment grace period.

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 continuation coverage is provided through a Federal, State or local government plan, 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 website at www.cms.hhs.gov/COBRAContinuationofCov/.

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:

Fax to:
U.S. Department of Labor
Employee Benefits Security Administration
Attn: COBRA Appeals
Fax number: 202.693.8849

Mail to:
U.S. Department of Labor
Employee Benefits Security Administration
Attn: COBRA Appeals
P.O.  Box 78038
Washington, DC 20013-9038

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 website 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.