Blue Cross Blue Shield COBRA form

COBRA and CAL-COBRA

Information on COBRA subsidies from the 2021 American Rescue Plan Act is available here.

Índice Show

Forms and manuals
How can I get a free cobra?
Who is eligible for Cobra in Texas?
What is Cal
How long do Cobra benefits last in California?

Form

Download

Continuation of Coverage Application (COBRA and Cal-COBRA)
For existing groups requesting effective dates of October 1, 2020, and later, this form replaces the "COBRA Continuation of Coverage Application”, the “Cal-COBRA Election”, the "Cal-COBRA Dental Election", and the “Continuing Group Coverage After Federal COBRA” forms. Use this form to apply for a continuation of coverage (federal COBRA or Cal-COBRA).

Download
(Fillable PDF)

Employer Notification of Qualifying Events under Cal-COBRA
This form replaces the “Employer Notification of Qualifying Events under Cal-COBRA (ENF)” form for groups requesting changes effective October 1, 2020, and later. Complete this form each time a covered employee has a qualifying event that causes them to be eligible for continuation coverage under the California Continuation Benefits Replacement Act (Cal-COBRA).

Download
(Fillable PDF)

Cal-COBRA Take-Over
New groups should use this form when changing carriers to Blue Shield for Cal-COBRA members covered under a previous carrier. Employers are responsible for notifying their Cal-COBRA members of the transition to a new carrier and Cal-COBRA members are required to fill out the form and submit to the Cal-COBRA team within 30 days of transition.

Download (Fillable PDF)

Forms and manuals

Manuals

Group Administration Manual (GAM)
The redesigned, easy-to-use GAM keeps you on top of the latest administrative and legislative topics. The manual includes links to applications and forms, a qualifying events chart, billing information, summary of benefits and coverage details and much more.

Enrollment Eligibility Date Calculator
New Hire Checklist
Employee Termination Checklist
Government Mandates

eBilling User Guide - Special Funded Groups
(PDF, 1.6MB - updated 03/09)

CMS Creditable Coverage Disclosure

Online forms

Address change form
Explanation of Benefits (EOB) order form
ID card order form

Miscellaneous forms

Navigate to the Adobe website to download the latest version of Acrobat Reader. Version 9.0 or higher is required.

Application for Plan 150 Cancer Only Plan and Hospital Indemnity Plan (HIP) *
(Form 5-14/105A)
Application and brochure for Secure 300 / Secure HIP
(Form 5-26)
Application for Secure 300 / Secure HIP application *
(Form 5-26A)
Authorization for Release of Protected Health Information (HIPAA Form) *
(Form 29-456)
- Spanish Version *
Authorization for the Release of Protected Health Information (PHI) relating to Substance Use Disorder *
(form 29-456A)
- Spanish Version *
Revocation of Authorization for the Release of Protected Health Information (HIPAA Form) *
(Form 29-457)
- Spanish Version *
Automatic Payment Authorization *
(Form MC806B)
Banking Change Form (for Self-Funded employers) *
(Form 84-5)
Billing Worksheet *
(Form 5-5)
Change Form for Group Coverage *
(Form 29-151)
- Spanish Version *
CMS SSN Declination Form (offsite link)
Continuation Coverage Rights Under COBRA Election Notice Template (offsite link)
Continuation Coverage Rights Under COBRA General Notice Template (offsite link)
Coverage of Handicapped Dependent Child Application *
(Form 15-411)
Dependent Child Affidavit *
(Form 29-158)
Duplicate Coverage Questions *
(Form 34-705)
Enrollment Form for Group Coverage *
(Form 40-127)
Please also complete life insurance applications if applicable: Life Insurance Forms
- Spanish Version *
Health Profile *
(Form MC547)
- Spanish Version *
HIPAA Designation Form *
(Form MC280)
Home Delivery Order Form (Mail Order Form) (offsite link)
USERRA Election Form *
(Form 29-297)
Waiver of Enrollment *
(Form 40-106)
- Spanish Version *

* You may fill out and print this form using your PDF reader program.

Claim forms

Blue Cross Blue Shield Global Core Claim Form (offsite link)
Cancer Plan Claim Form *
(Form 29-134)
Claim Appeal Form *
(Form 34-730WEB)
- Spanish version *
Claim Appeal Representative Authorization Form *
(Form 29-58)
Hospital Indemnity Plan Claim Form *
(Form 29-142)
Member Claim Form *
Use this form to submit a claim for a prescription drug charge for any BlueRx product, excluding BlueRx Direct.
(Form 34-4)
- Spanish version *
Prescription Drug Claim Form (Prime Therapeutics) *
Use this form to submit a claim for a prescription drug charge if you have BlueRx Direct.
(Form 34-148)

* You may fill out and print this form using your PDF reader program.

Further (formerly SelectAccount) forms and guides

FSA Plan Design Guide *
(Form X22002)
HRA Plan Design Guide *
(Form X22003)
HRA Enrollment *
(Form X21988)
HSA Plan Design Guide *
(Form XX22001)
HSA Application *
(Form X21989)
HSA Reference Guide
(Form X22000)

* You may fill out and print this form using your PDF reader program.

Advance Insurance Company of Kansas (AICK)

Visit the AICK forms page for all Advance Insurance forms

How can I get a free cobra?

Players cannot directly acquire the Cobra Rage Bundle or the Cobra Fist. Instead, they will have to spin for the Legendary Cobra Egg, which can then be used to get the rare outfit. Users can get the following items from the new event in the battle royale title: Cobra Statue Loot Box at 1 Legendary Cobra Egg.

Who is eligible for Cobra in Texas?

Plan Coverage – Group health plans for employers with 20 or more employees on more than 50 percent of its typical business days in the previous calendar year are subject to COBRA. Both full and part-time employees are counted to determine whether a plan is subject to COBRA.

What is Cal

Much like federal COBRA, Cal-COBRA is a California law that lets you keep your group health plan when your job ends or your hours are cut. It may also be available to people who have exhausted their federal COBRA. Cal-COBRA applies to employers and group health plans that cover from two to 19 employees.

How long do Cobra benefits last in California?

Duration of Coverage Continuation Cal-COBRA allows individuals to continue their group health coverage for up to 36 months. For individuals covered under federal COBRA, Cal-COBRA may also be used to extend health coverage for a combined period of up to 36 months.