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A complete COBRA IDOC Application Packet consists of the following three items:
To comply with Federal regulations, it is the department's responsibility to provide an employee with a complete COBRA IDOC Application Packet when an employee loses eligibility for a UC-sponsored medical, dental or vision plan.
COBRA Notification Document (IDOC)
The IDOC is available through PPS on page 2 of the Document Selection Menu (IDOC function). There are five types of documents available:
- Separation (for reasons other than gross misconduct)
- Layoff
- Retirement
- Reduction in hours resulting in loss of eligibility
- Approved leave without pay
Mailing Addresses and Premium Information
This document contains the current-year premium rates for each health plan carrier and the addresses to which the COBRA application and one month's premium is to be sent.
Please place checkmarks in the boxes next to the name of the health plan in which the employee is enrolled before printing this document.
Your COBRA Continuation Coverage Rights-Important Information
This notice has important information regarding COBRA regulations that the employee must be made aware of. Please print this document.
Instructions for providing the COBRA IDOC Application Packet
Following these steps to complete the COBRA notification process.
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Process appropriate transaction in PPS and print corresponding personnel action IDOC (i.e. Separation or Change-in-Status IDOC) |
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After processing appropriate PPS transaction, print corresponding COBRA Notification Document (IDOC)
- At IDOC menu, go to Page 2 (F8-key)
- Tab cursor to "COBRA Notification Documents - All" and type "S"
- Press F5-key to be taken to the COBRA sub menu
- Tab cursor to appropriate employment action and type "S"
- Press F5-key to print IDOC
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Important Notes:
- PPS will automatically print two copies - An "Employee Copy" and a "Department/Benefits Office Copy"
- Print the IDOC no later than the date the employee's coverage ends (see IINS screen in PPS)
- Verify the accuracy of all dates indicated on IDOC and notify the Benefits Office of any discrepancy
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Print other notification required documents
In addition to the IDOC, the complete Application Packet also consists of the following:
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Required signatures
If available, the employee should sign both copies of the IDOC before issuing the complete Application Packet. If the employee is unavailable, indicate so on the department copy.
- Employee completes the following:
- COBRA Continuation Applicant Signature
- Date (i.e. date of signature)
- Print Name
- Daytime Phone
- Department completes the following:
- Benefits Representative Signature
As a Department Benefits Assistant or PPS Processor, you are authorized and required to sign this document.
- Date (i.e. date of signature)
- Campus (i.e. Davis or Davis Medical Center)
- Office Phone
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Retain Department/Benefits copy of COBRA IDOC
Place in your employee's personnel file. Your office must retain a copy of the IDOC (or entire packet) for five years |
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Provide complete COBRA IDOC Application Packet to employee
You may send the packet by U.S. mail or hand-deliver to employee. Sending it by U.S. mail is preferred. |
Additional information available through http://atyourservice.ucop.edu. Contact the Benefits Office if you have any questions.
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