Sample Checklist for COBRA Recordkeeping
INDIVIDUAL'S COBRA RECORD
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1.
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Date initial COBRA notice sent [when employee becomes covered under plan]
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2.
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Date employee and spouse confirmed receipt of initial notice
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Qualifying Event Other than Divorce or Loss of Dependent Status
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3.
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Date qualifying event occurred
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4.
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Date 30 days after date in (3) [deadline for employer to notify administrator]
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5.
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Date on which administrator notified
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6.
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Date 14 days after date in (5) [when administrator must notify qualified beneficiary]
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7.
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Date coverage is lost under plan by reason of qualifying event
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8.
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Date qualified beneficiary notified of election rights
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9.
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Date 60 days after later of date in (7) or (8) [deadline for making election]
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10.
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Date on which qualified beneficiary makes COBRA election
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Divorce or Loss of Dependent Status Qualifying Event
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11.
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Date of divorce or loss of dependent status
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12.
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Date coverage is lost under plan by reason of qualifying event
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13.
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Date 60 days after later of date in (11) or (12) [deadline for employee or qualified beneficiary to notify administrator]
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14.
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Date employee or qualified beneficiary notified administrator of qualifying event.
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15.
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Date 14 days after date in (14) [when administrator must notify qualified beneficiary]
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16.
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Date administrator notified qualified beneficiary of election rights
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17.
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Date 60 days after later of date in (15) or (16) [deadline for making election]
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18.
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Date on which qualified beneficiary makes election
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Waiver and Revocation of COBRA Rights
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19.
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Date of waiver of COBRA rights
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20.
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Date in (9) or (17), whichever is applicable [deadline for making election]
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21.
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Date of revocation of waiver
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Payment of COBRA Premiums
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22.
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Date 45 days after date in (10) or (18), whichever is applicable-initial premium due date [payment is due for each month for which the 30-day grace period has expired]
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23.
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Date payment of initial premium made
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24.
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For each remaining month-due date, end of grace period, actual payment date:
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Month
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Due Date
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End of 30-Day
Grace Period
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Payment Date
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25.
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Premium not paid timely, coverage terminated
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Changes in Premiums, Status, Coverage, etc.
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26.
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Change in COBRA premium-New Determination Period:
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a.
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Notification of change made
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b.
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Effective date of change
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c.
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New premium determined
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27.
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Disability determination
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a.
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Date of determination
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b.
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60 days after date in 27(a)
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c.
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Date of notification
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d.
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Month COBRA rate changes to 150%
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28.
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Date of secondary qualifying event
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29.
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Change of coverage:
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a.
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Effective date of change
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b.
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New premium determined
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30.
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Medicare entitlement:
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a.
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Effective date of employee's entitlement
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b.
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Employee's coverage terminated
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c.
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Extension of coverage for other beneficiaries
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d.
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Effective date of other beneficiaries' coverage
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31.
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Date of coverage under another health plan [coverage may be terminated only if other coverage has no exclusion with respect to preexisting condition]
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