California Consolidated Omnibus Budget Reconciliation Act (CalCOBRA) Notice and Election Form

Entity Mandating Form: California Department of Insurance (DIC) and the California Department of Managed Health Care (DMHC).

Applicability: All employers with between two and 19 full time employees who were covered by a group healthcare policy on at least 50 percent of working days during the preceding calendar year or the preceding calendar quarter, if the employer was not in business during any part of the preceding calendar year. (Note: Employees covered under self-insurance policies are not eligible, nor are employees who purchase individual healthcare insurance policies.)

Distribution Specifications: An employer must notify a terminated employee of their CalCOBRA continuation rights at least 30 days prior to the expiration of their 18 months of federal COBRA coverage. (The total extension of coverage (including the 18 months of federal coverage) cannot exceed 36 months under CalCOBRA, but only if the employee became eligible for COBRA after January 1, 2003 and where the employer's "group master policy" is issued in the State of California.)

Obtaining this Form: An employer can obtain a CalCOBRA Notice and Election Form by contacting its health care insurance carrier.

Additional Resources

California Department of Insurance (DIC) Website

California Department of Managed Health Care (DMHC) Website