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Consolidated Omnibus Budget Reconciliation Act "COBRA" PERS-HBD-85 (Rev 10/17). Consolidated Omnibus Budget Reconciliation Act "COBRA" PERS-HBD-85 (Rev 10/17)

17) 2025

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The document provides instructions for completing the COBRA enrollment form (PERS-HBD-85) for health coverage continuation under the Consolidated Omnibus Budget Reconciliation Act. It outlines the necessary information required from enrollees, including details about qualifying events, personal information, dependent information, and carrier details. Additionally, it emphasizes the importance of timely reporting of enrollment changes and includes privacy information regarding the handling of personal data.

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Click ‘Get Form’ to open it in the editor.
In Part A, select the type of action: check 'NEW' for a new enrollment or 'CHANGE' if you are modifying existing coverage. Specify the qualifying event and its date.
In Part B, fill in the COBRA enrollee's information, including name, address, and social security number. If applicable, identify the subscriber.
Part C requires you to provide the name and address of your health plan. Ensure that you continue with the same coverage as before unless changing during Open Enrollment.
In Part D, list all family members to be enrolled. Use action codes 'A' for adding and 'D' for deleting individuals from coverage.
Complete Part F by signing and dating the form to confirm your agreement to pay premiums directly to the carrier.
Finally, ensure that Parts G is filled out by your agency's health benefits officer after submission.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (45 Votes)
2018	4.3 Satisfied (178 Votes)
2013	4.3 Satisfied (72 Votes)

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What is the purpose of the Consolidated Omnibus Budget Reconciliation Act of 1985?

The Consolidated Omnibus Budget Reconciliation Act (COBRA) gives workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances such as voluntary or involuntary job loss,

What is the purpose of the Consolidated Omnibus Budget Reconciliation Act?

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) - COBRA is a Federal law that provides rights to temporary continuation of group health plan coverage for certain employees, retirees and family members at group rates when coverage is lost due to certain qualifying events.

What is the Omnibus Budget Act?

The Omnibus Budget Reconciliation Act of 1993 (or OBRA-93) was a federal law that was enacted by the 103rd United States Congress and signed into law by President Bill Clinton on August 10, 1993. It has also been unofficially referred to as the Deficit Reduction Act of 1993.

Who is eligible for COBRA in CA?

COBRA applies only to companies with at least 20 employees. Employers are required to notify you when you are eligible for these benefits. If you elect to receive COBRA benefits, you will pay 100% of the total premium for your benefits plus a 2% administrative fee.

What is the consolidated omnibus budget reconciliation act COBRA?

The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a federal law that may let you keep your employer group health plan coverage for a limited time after your employment ends (or if you lose coverage as a spouse or dependent of the covered employee).

Consolidated Omnibus Budget Reconciliation Act "COBRA" PERS-HBD-85 (Rev 10/17). Consolidated Omnibus Budget Reconciliation Act "COBRA" PERS-HBD-85 (Rev 10/17) 2025

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