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- Cal-Cobra Enrollment Request Form - MHN
Get Cal-Cobra Enrollment Request Form - MHN
Fits. Mail to: Managed Health Network Attn: Membership Accounting Cal-COBRA 1600 Los Gamos Drive, Suite 300 San Rafael, CA 94903 Name (last, first, middle initial): Current Member ID Number (if available): Former Employer: Address: Date of Birth:.
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FAQ
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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.
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Your employer must mail you the COBRA information and forms within 14 days after receiving notification of the qualifying event. You are responsible for making sure your COBRA coverage goes into and stays in effect - if you do not ask for COBRA coverage before the deadline, you may lose your right to COBRA coverage.
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Personnel staff are usually notified when a covered employee has died, voluntarily or involuntarily terminated employment, or reduced hours.
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All employers are responsible for administering their own federal COBRA program. Blue Shield administers Cal-COBRA when an employer is subject to it under state law. Groups have the option to self-administer their federal COBRA benefits.
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Certain events, such as layoffs, death and divorce, trigger eligibility for COBRA or CalCOBRA. The plan administrator must notify the employee and his/her covered spouse of their right to continue coverage within 44 days of the event, except during a legal separation or divorce.
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Employers should ensure that a Cal-COBRA General Notice is provided to all eligible group health care participants and their qualified beneficiaries within 90 days of becoming eligible to participate in the group health plan.
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