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The federal law, COBRA, allows most former employees (qualified beneficiaries) to continue their health insurance coverage for 18 months, however, due to the high cost of health insurance most people are unable to afford to take advantage of COBRA. Recognizing this problem, the American Recovery and Reinvestment Act of 2009, Public Law 111-5 was enacted on February 17, 2009 and establishes an employer-provided subsidy for health insurance and other medical-related insurance premiums for employees who experience a qualifying event related to an involuntarily termination of employment between September 1, 2008 and February 28, 2010. If eligible for COBRA premium assistance, the former employer pays 65% of the health insurance and other medical-related insurance premiums for the first 15 months of COBRA coverage. After 15 months, the qualified beneficiary is responsible for the full premium due.

Eligibility Requirements and Insurance Premium Information

• Eligibility Requirements for COBRA Premium Assistance for Employees of UW System Institutions (Revised 1/22/10)
  
  
• Combined 2009 and 2010 Insurance Premium Rate Sheets for Employees Covered under the Wisconsin Retirement System (WRS) - includes health, dental and vision premiums
  
  
• Combined 2009 and 2010 Insurance Premium Rate Sheets for Employees Covered Under the Graduate Assistant Health Insurance Plan (student assistants, employees-in-training, short-term academic staff)
  

Employee Forms

• Request for Treatment as an Assistance Eligible Individual - used by employees and/or their dependents to request treatment as an assistance eligible individual for COBRA premium assistance purposes. (Rev 1/28/10)
  
  
• State Group Health Insurance COBRA Continuation Form (ET-2311) - PDF or Word
  
  
• Anthem DentalBlue Dental Insurance Continuation Form (Rev 12/23/09)
  
  
• EPIC Dental & Excess Medical + EyeMed Vision Discount Continuation Form (Rev 12/23/09)
  
  
• VSP Vision Continuation Form
  
  
• Participant Notification (UWS 92) - used by employees and/or their dependents to notify employer and health, dental and vision plans that they are no longer eligible for COBRA premium assistance due to eligibility for other group health insurance and/or Medicare. (Rev 12/23/09)

• Appeal Form - used to request review by Centers for Medicare and Medicaid Services (CMS) if you are denied COBRA premium assistance for which you believe you are eligible.
  
  
• Apuntes informativos en español - COBRA Fact Sheet in Spanish (Added 2/3/10)

For Employers

• COBRA Premium Assistance Process for UW System Institutions - this is a step-by-step guide outlining each institution's responsibilities in regards to implementing COBRA premium assistance provisions. (Rev 1/22/10)
  
  
• COBRA Cover Letter for Employees Whose Terminate Employment on or before February 28, 2010 - this letter should be sent to employees and/or dependents who have a COBRA-qualifying event on or before February 28, 2010. All employees who terminate employment on or before February 28, 2010 should receive this letter and the full COBRA subsidy packet. Each institution should place this letter on its own letterhead and complete the employee-specific information in the letter. (Revised 12/23/09)
  
  
• Special insert for former employees who previously received COBRA subsidy mailings. Include this in the COBRA packet to advise individuals of the expansion of the COBRA premium subsidy, effective December 2009. This should be sent to all individuals who previously received a mailing and terminated during or after the 2009 October A or October unclassified payrolls.
  
  
• COBRA Premium Assistance Informational Packet (PDF or Word) that institutions must send to all employees and/or dependents who are eligible for COBRA. This packet is not individualized and should be sent to employees in its current format. (Revised 1/22/10)
  
  
  • In the packet, include the rate sheet:
    
    
    • Combined 2009 and 2010 Insurance Premium Rate Sheets for Employees Covered under the Wisconsin Retirement System (WRS) - includes health, dental and vision premiums
      
      
    • Combined 2009 and 2010 Insurance Premium Rate Sheets for Employees Covered Under the Graduate Assistant Health Insurance Plan (student assistants, employees-in-training, short-term academic staff)
      
      
  • In the packet, include the appropriate COBRA election forms:
    
    
    • State Group Health Insurance COBRA Continuation Form (ET-2311) - PDF or Word
      
      
    • Anthem DentalBlue Dental Insurance Continuation Form (Rev 12/23/09)
      
      
    • EPIC Dental & Excess Medical + EyeMed Vision Discount Continuation Form (Rev 12/23/09)
      
      
    • VSP Vision Continuation Form
      
      
• Instructions for Submitting Payment for COBRA Premium Assistance (UWS 90) - employer must send this form along with the completed Request for Treatment as an Assistance Eligible Individual to all employees who apply for and are eligible for COBRA premium assistance. Employers must also submit a copy of this form to the UW Service Center. (Rev 12/23/09)
  
  
• Denial of Your Request as Treatment as an Assistance Eligible Individual (UWS 91) - employer must send this form along with the completed Request for Treatment as an Assistance Eligible Individual to all employees who apply for but are not eligible for COBRA premium assistance. This form should also be sent to an employee's dependent who applies for their own continuation coverage but is not eligible for COBRA premium assistance. (Rev 12/23/09)
  
  
• COBRA Tracking Document - this spreadsheet is a template to track COBRA notices sent and employees who apply for COBRA premium assistance.
  
  
• COBRA: Answers for Employers (IRS Website)

Layoff Resources

• How Layoff Impacts Your Benefits (UWS 41) - For Employees Under Minimum Retirement Age (age 55 for most employees, age 50 for protectives) (Revised 1/15/10)
  
  
• How Layoff Impacts Your Benefits (UWS 42) - For Employees At or Above Minimum Retirement Age (age 55 for most employees, age 50 for protectives) (Revised 1/15/10)
  
  
• Health Insurance Premium Payment at Layoff (UWS 40) - the employer should send this form to an employee when notified of an impending layoff. This form outlines the options an employee has regarding health insurance upon termination due to layoff (PDF or Word). (Revised 1/15/10)
  
  
• UWSA's Layoff Page

U.S. Department of Labor and IRS Resources

• Fact Sheet: COBRA Premium Reduction
  
  
• FAQs About COBRA Continuation Health Coverage for Employees
  
  
• FAQs About COBRA Continuation Health Coverage for Employers
  
  
• U.S Department of Labor webpage for COBRA Continuation Coverage Assistance Under the American Recovery and Reinvestment Act of 2009
  
  
• IRS Website Dedicated to the COBRA Premium Subsidy
  
  
• IRS Notice 2009-27: Premium Assistance for COBRA Benefits

 

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This document was last revised on January 28, 2010