Client Forms

ARPA Model Notices

FAQS About Cobra Premium Assistance Under ARPA 2021

Set out below are Frequently Asked Questions (FAQs) regarding implementation of certain provisions of the American Rescue Plan Act of 2021 (ARP),…


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1 – Model Extended Election Period Notice 4-21

(For use by group health plans for qualified beneficiaries currently enrolled in COBRA continuation coverage, due to a reduction in hours or involuntary termination…


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2 – Model Extended Election Period Notice 4-21

(For use by group health plans for qualified beneficiaries currently enrolled in STATE CONTINUATION continuation coverage, due to a reduction in hours or involuntary termination…


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3 – Summary of Provisions

President Biden signed H.R. 1319, the American Rescue Plan Act of 2021 (ARP), on March 11, 2021. 


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4 – Model General and Election Notice 4-21​

(For use by group health plans for qualified beneficiaries who have qualifying events occurring from April 1, 2021 through September 30, 2021)…


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5 – Model Alternative Election Notice State Continuation 4-21

(For use by insured coverage subject to state continuation requirements between April 1, 2021 and September 30, 2021.)…


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6 – Notice of Premium Assistance Expiration Premium 4-21

(For use by group health plans to Assistance Eligible Individuals 15-45 days before their premium assistance expires)…


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Carrier Continuation of Coverage Forms

Employee Enrollment Form – United Healthcare

Notice for Employers who select a Consumer Choice plan: You have the option to choose this health care plan that, either in whole or in part, does not provide state-mandated health benefits normally requireed in evidences of coverage or accident and sickness policies in Texas…


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Texas Small Group Employee Enrollment/Change Form – Aetna

You have the option to choose a Consumer Choice of Benefits Health Insurance Plan or Health Maintenance Organization health care plan that, either in whole or in part, does not provide state-mandated health benefits….


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All Savers Plan Participant Enrollment

Identification Form for All Savers Plan participants – United Healthcare


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BlueCross BlueShield of Texas -6 Month Continuation Form

Any individual who was covered under a group health plan either as the employee, the spouse of the employee, or the
dependent child of the employee and has completed their continuation coverage under COBRA is eligible for an additional six
(6) months…


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BlueCross BlueShield of Texas – 9 Month Continuation Form

Any individual who is covered under a group health plan either as the employee, the spouse of the employee, or the dependent child of the employee is eligible for the nine (9) month…


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BlueCross and BlueShield – Cobra Qualifying Events

Any individual who, on the day before a qualifying event, is covered under a group health plan either as the employee, the spouse of the employee, or the dependent child of the employee and loses coverage due to specific COBRA Qualifying Events…


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Covid-19 Vaccines Information for BCBS

Covid-19 Vaccines

Now that the Food and Drug Administration (FDA) has approved COVID-19 vaccines for use, here are some things to keep in mind about the COVID-19 vaccines: 


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Employee Health Benefits Census Sheet

THB Health Benefits Calculation Sheet

Excel spreadsheet to list information and contact details for employee calculation of benefits…


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Cobra Continuation Notice

Model COBRA Continuation Coverage Election Notice

The Department of Labor has developed a model Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) continuation coverage election notice that the Plan may use to provide the election notice…


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