COBRA Plan and Rate Change Form
Use this form to notify CONEXIS of rate changes for existing plans or new plans that need to be added to your CONEXIS
account. Please complete this form and return it to CONEXIS by email or fax no later than 45 days prior to the start of
your determination period (see below for more information regarding the determination period). Once received,
CONEXIS will communicate the changes to all appropriate COBRA participants along with new payment invoices.
A Special Note for California Employers
California Insurance Code § 10199.1(b) prohibits fully-insured group health plans subject to California state insurance
laws from increasing premiums without providing written notice of the increase at least 60 days prior to the effective date
of the increase. To help ensure your affected COBRA participants are provided timely notice, we must receive this
completed form no later than 75 days prior to the start of your determination period.
Completing this Form
Please complete sections 1 and 2 immediately below, as well as section 3, beginning on page 4 of this document. If you
are adding new plans at this time, you must also complete section 4, beginning on page 7 of this document. You may
provide information for up to six current plans and six new plans using this form. If you need to provide additional
information, please complete an additional copy of this form or contact your CONEXIS representative for assistance.
Be sure to complete the Employer Certification on page 3 prior to submitting this form to CONEXIS.
Section 1 – Company Information
1.1
1.2
1.3
Company Name
Tax ID
COBRA Renewal Contact
Name
Email Address
Phone Number
Section 2 – Plan Changes
2.1
2.2
Are any of your current plans renewing without a change in rates?
Yes
No If yes, please list the plan names below
Plan Name:
Plan Name:
Plan Name:
Plan Name:
Plan Name:
Plan Name:
Plan Name:
Plan Name:
Plan Name:
Plan Name:
Are any of your current plans terminating?
Yes
No If yes, please list the plan names and termination dates below
Plan Name:
Date:
Plan Name:
Date:
Plan Name:
Date:
Plan Name:
Date:
Plan Name:
Date:
Plan Name:
Date:
Plan Name:
Date:
Plan Name:
Date:
Plan Name:
Date:
Plan Name:
Date:
Plan and Rate Change Form
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COBRA Plan and Rate Change Form
2.3
Are you adding any new plans?
Yes
No If yes, you must complete section 4 below.
2.4
Are these changes occurring as part of an open enrollment period?
Yes
No If yes, please provide the start date
and end date
2.5
of the open enrollment period.
Do you want to contract with CONEXIS to perform open enrollment services?
Additional fees apply. If you choose “yes”, please sign and return our Open Enrollment Services Appendix.
Yes
No
NOTE: CONEXIS provides rate increase notifications and updated payment invoices to affected COBRA
beneficiaries as a standard service at no additional charge. Declining open enrollment services does not impact
these notices, but if you do not select our open enrollment services, you or your designated service provider must
provide open enrollment information and materials to your COBRA beneficiaries.
IMPORTANT: If you do not select open enrollment services through CONEXIS, you must notify CONEXIS of
the enrollment decision made by each affected COBRA participant so we may update our system and provide
accurate billing and support services to these participants.
A Special Note about Premium Remittance
CONEXIS will continue the current process of premium remittance (sending the premiums we collect from COBRA
participants to the employer or to the carrier) unless otherwise notified. We strongly recommend that any changes to your
current process are made only during the annual renewal period, prior to new rates or plans being added for the upcoming
plan year.
An Explanation of the Determination Period
COBRA regulations include a requirement that all plans must determine premium amounts in advance of a 12-month
period known as the “determination period.” The determination period can be any 12-month period selected by the plan,
but it must be applied consistently from year to year.
Many plans use the plan year as the determination period, but in certain circumstances it may be better if the
determination period differs from the plan year. For example, if the plan year differs from the coverage period (i.e., the
period for which the insurer sets premiums), the employer may prefer to use the coverage period as the determination
period instead of the plan year.
Example. ABC Company offers a group medical plan through an insurance carrier. The plan year
established by the company runs from June 1 through May 31, to coincide with the company’s fiscal year.
However, the insurance carrier sets rates on a calendar year basis. ABC Company may wish to set the
determination period to match this calendar year cycle so that any increases imposed by the insurance
carrier can be passed along as of the effective date. If ABC Company chooses to set the determination
period to begin on June 1, any premium increases imposed by the insurance carrier effective January 1
cannot be passed along to the COBRA participants until the beginning of the next determination period
on June 1.
COBRA regulations do not expressly prohibit or permit changes to a plan’s determination period. The regulations state
only that the determination period must be a 12-month period that is applied consistently from year to year. Because of
the lack of guidance regarding changing a plan’s determination period, employers should consult with legal counsel
before changing a determination period.
To maintain compliance with COBRA regulations, an employer may not increase COBRA premiums after the
start of the determination period except in limited instances. Although a proactive change is permitted in these
limited scenarios, in no event may a change be made retroactively. IRS regulations explicitly require that “the
determination of the applicable premium be made for a period of 12 months and that the determination be made
Plan and Rate Change Form
Copyright ©2012 CONEXIS Benefits Administrators, LP. All Rights Reserved.
2
COBRA Plan and Rate Change Form
before the beginning of the period. Therefore, the final regulations do not permit an increase in the applicable
premium during the 12-month determination period.”
IMPORTANT: Any shortfall in premium payments by COBRA participants that is due to late
notification of rate changes to CONEXIS is the responsibility of the employer. Failure by the employer to
submit payment to the carrier for these shortfalls may result in the termination of the plan.
Employer Certification
By submitting this completed form, you certify that the information provided in this form is current and accurate to the
best of your knowledge. You further certify that you understand that it is the employer’s responsibility to advise qualified
beneficiaries and CONEXIS of any changes to their benefits. Failure to do so in a timely manner may result in the
employer being responsible to cover a shortfall in premium payments to the carrier. As requested by the employer,
CONEXIS will send notice of any rate change and open enrollment information to all current qualified beneficiaries
known to CONEXIS.
Employer Representative
Name
Date
IMPORTANT: Remember to complete sections 3 and 4 below, as applicable, prior to submitting this form to CONEXIS.
Plan and Rate Change Form
Copyright ©2012 CONEXIS Benefits Administrators, LP. All Rights Reserved.
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COBRA Plan and Rate Change Form
Section 3 – Current Plans and Rates
Please use the table(s) below to provide information for each current COBRA eligible plan that is changing rates.
Current Plan #1
Plan Name
Effective Date of Change
Rate Information
Please enter the monthly premium rate for each applicable category. Do not add the 2% COBRA administration fee.
Coverage Level
Current
New
Coverage Level
Current
New
Employee Only
$
$
Spouse Only
$
$
Employee + Spouse
$
$
Spouse + Child
$
$
Employee + Child
$
$
Spouse + Children
$
$
Employee + Children
Employee + Famuly
Employee + Family
$
$
Child Only
$
$
$
$
Children Only
$
$
Individual Only
$
$
Individual + 1
$
$
Individual + 2 or more
$
$
Three Tier Plans
Current Plan #2
Plan Name
Effective Date of Change
Rate Information
Please enter the monthly premium rate for each applicable category. Do not add the 2% COBRA administration fee.
Coverage Level
Current
New
Coverage Level
Current
New
Employee Only
$
$
Spouse Only
$
$
Employee + Spouse
$
$
Spouse + Child
$
$
Employee + Child
$
$
Spouse + Children
$
$
Employee + Children
Employee + Famuly
Employee + Family
$
$
Child Only
$
$
$
$
Children Only
$
$
Individual Only
$
$
Individual + 1
$
$
Individual + 2 or more
$
$
Three Tier Plans
Plan and Rate Change Form
Copyright ©2012 CONEXIS Benefits Administrators, LP. All Rights Reserved.
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COBRA Plan and Rate Change Form
Current Plan #3
Plan Name
Effective Date of Change
Rate Information
Please enter the monthly premium rate for each applicable category. Do not add the 2% COBRA administration fee.
Coverage Level
Current
New
Coverage Level
Current
New
Employee Only
$
$
Spouse Only
$
$
Employee + Spouse
$
$
Spouse + Child
$
$
Employee + Child
$
$
Spouse + Children
$
$
Employee + Children
Employee + Famuly
Employee + Family
$
$
Child Only
$
$
$
$
Children Only
$
$
Individual Only
$
$
Individual + 1
$
$
Individual + 2 or more
$
$
Three Tier Plans
Current Plan #4
Plan Name
Effective Date of Change
Rate Information
Please enter the monthly premium rate for each applicable category. Do not add the 2% COBRA administration fee.
Coverage Level
Current
New
Coverage Level
Current
New
Employee Only
$
$
Spouse Only
$
$
Employee + Spouse
$
$
Spouse + Child
$
$
Employee + Child
$
$
Spouse + Children
$
$
Employee + Children
Employee + Famuly
Employee + Family
$
$
Child Only
$
$
$
$
Children Only
$
$
Individual Only
$
$
Individual + 1
$
$
Individual + 2 or more
$
$
Three Tier Plans
Plan and Rate Change Form
Copyright ©2012 CONEXIS Benefits Administrators, LP. All Rights Reserved.
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COBRA Plan and Rate Change Form
Current Plan #5
Plan Name
Effective Date of Change
Rate Information
Please enter the monthly premium rate for each applicable category. Do not add the 2% COBRA administration fee.
Coverage Level
Current
New
Coverage Level
Current
New
Employee Only
$
$
Spouse Only
$
$
Employee + Spouse
$
$
Spouse + Child
$
$
Employee + Child
$
$
Spouse + Children
$
$
Employee + Children
Employee + Famuly
Employee + Family
$
$
Child Only
$
$
$
$
Children Only
$
$
Individual Only
$
$
Individual + 1
$
$
Individual + 2 or more
$
$
Three Tier Plans
Current Plan #6
Plan Name
Effective Date of Change
Rate Information
Please enter the monthly premium rate for each applicable category. Do not add the 2% COBRA administration fee.
Coverage Level
Current
New
Coverage Level
Current
New
Employee Only
$
$
Spouse Only
$
$
Employee + Spouse
$
$
Spouse + Child
$
$
Employee + Child
$
$
Spouse + Children
$
$
Employee + Children
Employee + Famuly
Employee + Family
$
$
Child Only
$
$
$
$
Children Only
$
$
Individual Only
$
$
Individual + 1
$
$
Individual + 2 or more
$
$
Three Tier Plans
Plan and Rate Change Form
Copyright ©2012 CONEXIS Benefits Administrators, LP. All Rights Reserved.
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COBRA Plan and Rate Change Form
Section 4 – New Plan Information
Complete the table(s) below if you answered “Yes” in section 2.3 above. Complete a separate table for each new plan.
New Plan #1
Carrier Name
Plan Name
Group Number/Plan ID (required for plan set up)
COBRA Sub-code(s) (for reporting eligibility)
Is this new plan intended to replace an existing
plan? If yes, provide the name of the plan that
is being replaced.
Yes
No
Plan Name:
Will COBRA participants on the old plan roll to the new plan or are
they required to respond with a new plan selection?
Roll to New Plan
New Plan Selection Required
Medical
HMO
PPO
POS
Other:
Dental
HMO
PPO
POS
Other:
Vision
HMO
PPO
POS
Other:
Rx
Health FSA
Other
Please specify:
Plan Type
Carrier Eligibility Contact Information
Name
Department
Email Address
Phone Number
Fax Number
Is there a waiting period?
Yes
No If yes, how long?
Days
Months
Following the waiting period, coverage is effective?
Immediately
Next Day
First of the Month
Dependent Child Age Limit
Full-time Student Age Limit
Is this plan bundled with other
Yes
No If yes, which plans:
plans?
When a qualifying event occurs,
On the day of the event
At the end of the month
when does coverage end?
Effective Date of Rates
Start Date:
End Date:
Rate Information
Please enter the monthly premium rate for each applicable category. Do not add the 2% COBRA administration fee.
Employee Only
Spouse Only
$
$
Employee + Spouse
Spouse + Child
$
$
Employee + Child
Spouse + Children
$
$
Employee + Children
Child Only
$
$
Employee
+
Famuly
Employee + Family
Children Only
$
$
Three Tier Plans
Individual Only
$
Individual + 1
$
Individual + 2 or more
$
Plan and Rate Change Form
Copyright ©2012 CONEXIS Benefits Administrators, LP. All Rights Reserved.
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COBRA Plan and Rate Change Form
New Plan #2
Carrier Name
Plan Name
Group Number/Plan ID (required for plan set up)
COBRA Sub-code(s) (for reporting eligibility)
Is this new plan intended to replace an existing
plan? If yes, provide the name of the plan that
is being replaced.
Yes
No
Plan Name:
Will COBRA participants on the old plan roll to the new plan or are
they required to respond with a new plan selection?
Roll to New Plan
New Plan Selection Required
Medical
HMO
PPO
POS
Other:
Dental
HMO
PPO
POS
Other:
Vision
HMO
PPO
POS
Other:
Rx
Health FSA
Other
Please specify:
Plan Type
Carrier Eligibility Contact Information
Name
Department
Email Address
Phone Number
Fax Number
Is there a waiting period?
Yes
No If yes, how long?
Days
Months
Following the waiting period, coverage is effective?
Immediately
Next Day
First of the Month
Dependent Child Age Limit
Full-time Student Age Limit
Is this plan bundled with other
Yes
No If yes, which plans:
plans?
When a qualifying event occurs,
On the day of the event
At the end of the month
when does coverage end?
Effective Date of Rates
Start Date:
End Date:
Rate Information
Please enter the monthly premium rate for each applicable category. Do not add the 2% COBRA administration fee.
Employee Only
Spouse Only
$
$
Employee + Spouse
Spouse + Child
$
$
Employee + Child
Spouse + Children
$
$
Employee + Children
Child Only
$
$
Employee
+
Famuly
Employee + Family
Children Only
$
$
Three Tier Plans
Individual Only
$
Individual + 1
$
Individual + 2 or more
$
Plan and Rate Change Form
Copyright ©2012 CONEXIS Benefits Administrators, LP. All Rights Reserved.
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COBRA Plan and Rate Change Form
New Plan #3
Carrier Name
Plan Name
Group Number/Plan ID (required for plan set up)
COBRA Sub-code(s) (for reporting eligibility)
Is this new plan intended to replace an existing
plan? If yes, provide the name of the plan that
is being replaced.
Yes
No
Plan Name:
Will COBRA participants on the old plan roll to the new plan or are
they required to respond with a new plan selection?
Roll to New Plan
New Plan Selection Required
Medical
HMO
PPO
POS
Other:
Dental
HMO
PPO
POS
Other:
Vision
HMO
PPO
POS
Other:
Rx
Health FSA
Other
Please specify:
Plan Type
Carrier Eligibility Contact Information
Name
Department
Email Address
Phone Number
Fax Number
Is there a waiting period?
Yes
No If yes, how long?
Days
Months
Following the waiting period, coverage is effective?
Immediately
Next Day
First of the Month
Dependent Child Age Limit
Full-time Student Age Limit
Is this plan bundled with other
Yes
No If yes, which plans:
plans?
When a qualifying event occurs,
On the day of the event
At the end of the month
when does coverage end?
Effective Date of Rates
Start Date:
End Date:
Rate Information
Please enter the monthly premium rate for each applicable category. Do not add the 2% COBRA administration fee.
Employee Only
Spouse Only
$
$
Employee + Spouse
Spouse + Child
$
$
Employee + Child
Spouse + Children
$
$
Employee + Children
Child Only
$
$
Employee
+
Famuly
Employee + Family
Children Only
$
$
Three Tier Plans
Individual Only
$
Individual + 1
$
Individual + 2 or more
$
Plan and Rate Change Form
Copyright ©2012 CONEXIS Benefits Administrators, LP. All Rights Reserved.
9
COBRA Plan and Rate Change Form
New Plan #4
Carrier Name
Plan Name
Group Number/Plan ID (required for plan set up)
COBRA Sub-code(s) (for reporting eligibility)
Is this new plan intended to replace an existing
plan? If yes, provide the name of the plan that
is being replaced.
Yes
No
Plan Name:
Will COBRA participants on the old plan roll to the new plan or are
they required to respond with a new plan selection?
Roll to New Plan
New Plan Selection Required
Medical
HMO
PPO
POS
Other:
Dental
HMO
PPO
POS
Other:
Vision
HMO
PPO
POS
Other:
Rx
Health FSA
Other
Please specify:
Plan Type
Carrier Eligibility Contact Information
Name
Department
Email Address
Phone Number
Fax Number
Is there a waiting period?
Yes
No If yes, how long?
Days
Months
Following the waiting period, coverage is effective?
Immediately
Next Day
First of the Month
Dependent Child Age Limit
Full-time Student Age Limit
Is this plan bundled with other
Yes
No If yes, which plans:
plans?
When a qualifying event occurs,
On the day of the event
At the end of the month
when does coverage end?
Effective Date of Rates
Start Date:
End Date:
Rate Information
Please enter the monthly premium rate for each applicable category. Do not add the 2% COBRA administration fee.
Employee Only
Spouse Only
$
$
Employee + Spouse
Spouse + Child
$
$
Employee + Child
Spouse + Children
$
$
Employee + Children
Child Only
$
$
Employee
+
Famuly
Employee + Family
Children Only
$
$
Three Tier Plans
Individual Only
$
Individual + 1
$
Individual + 2 or more
$
Plan and Rate Change Form
Copyright ©2012 CONEXIS Benefits Administrators, LP. All Rights Reserved.
10
COBRA Plan and Rate Change Form
New Plan #5
Carrier Name
Plan Name
Group Number/Plan ID (required for plan set up)
COBRA Sub-code(s) (for reporting eligibility)
Is this new plan intended to replace an existing
plan? If yes, provide the name of the plan that
is being replaced.
Yes
No
Plan Name:
Will COBRA participants on the old plan roll to the new plan or are
they required to respond with a new plan selection?
Roll to New Plan
New Plan Selection Required
Medical
HMO
PPO
POS
Other:
Dental
HMO
PPO
POS
Other:
Vision
HMO
PPO
POS
Other:
Rx
Health FSA
Other
Please specify:
Plan Type
Carrier Eligibility Contact Information
Name
Department
Email Address
Phone Number
Fax Number
Is there a waiting period?
Yes
No If yes, how long?
Days
Months
Following the waiting period, coverage is effective?
Immediately
Next Day
First of the Month
Dependent Child Age Limit
Full-time Student Age Limit
Is this plan bundled with other
Yes
No If yes, which plans:
plans?
When a qualifying event occurs,
On the day of the event
At the end of the month
when does coverage end?
Effective Date of Rates
Start Date:
End Date:
Rate Information
Please enter the monthly premium rate for each applicable category. Do not add the 2% COBRA administration fee.
Employee Only
Spouse Only
$
$
Employee + Spouse
Spouse + Child
$
$
Employee + Child
Spouse + Children
$
$
Employee + Children
Child Only
$
$
Employee
+
Famuly
Employee + Family
Children Only
$
$
Three Tier Plans
Individual Only
$
Individual + 1
$
Individual + 2 or more
$
Plan and Rate Change Form
Copyright ©2012 CONEXIS Benefits Administrators, LP. All Rights Reserved.
11
COBRA Plan and Rate Change Form
New Plan #6
Carrier Name
Plan Name
Group Number/Plan ID (required for plan set up)
COBRA Sub-code(s) (for reporting eligibility)
Is this new plan intended to replace an existing
plan? If yes, provide the name of the plan that
is being replaced.
Yes
No
Plan Name:
Will COBRA participants on the old plan roll to the new plan or are
they required to respond with a new plan selection?
Roll to New Plan
New Plan Selection Required
Medical
HMO
PPO
POS
Other:
Dental
HMO
PPO
POS
Other:
Vision
HMO
PPO
POS
Other:
Rx
Health FSA
Other
Please specify:
Plan Type
Carrier Eligibility Contact Information
Name
Department
Email Address
Phone Number
Fax Number
Is there a waiting period?
Yes
No If yes, how long?
Days
Months
Following the waiting period, coverage is effective?
Immediately
Next Day
First of the Month
Dependent Child Age Limit
Full-time Student Age Limit
Is this plan bundled with other
Yes
No If yes, which plans:
plans?
When a qualifying event occurs,
On the day of the event
At the end of the month
when does coverage end?
Effective Date of Rates
Start Date:
End Date:
Rate Information
Please enter the monthly premium rate for each applicable category. Do not add the 2% COBRA administration fee.
Employee Only
Spouse Only
$
$
Employee + Spouse
Spouse + Child
$
$
Employee + Child
Spouse + Children
$
$
Employee + Children
Child Only
$
$
Employee
+
Famuly
Employee + Family
Children Only
$
$
Three Tier Plans
Individual Only
$
Individual + 1
$
Individual + 2 or more
$
Plan and Rate Change Form
Copyright ©2012 CONEXIS Benefits Administrators, LP. All Rights Reserved.
12