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COBRA Subsidy Form Upload

Summary of the COBRA Premium Assistance

Provisions under the American Rescue Plan Act of 2021

President Biden signed H.R. 1319, the American Rescue Plan Act of 2021 (ARP), on March 11, 2021. This law subsidizes the full COBRA premium for “Assistance Eligible Individuals” for periods of coverage from April 1, 2021 through September 30, 2021.

To be eligible for the premium assistance, you:

  • MUST have a COBRA qualifying event that is a reduction in hours or an involuntary termination of a covered employee’s employment;
  • MUST elect COBRA continuation coverage;
  • MUST NOT be eligible for Medicare; AND
  • MUST NOT be eligible for coverage under any other group health plan, such as a plan sponsored by a new employer or a spouse’s employer. *
* This restriction does not include coverage under a plan that provides only excepted benefits, a qualified small employer health reimbursement arrangement, or coverage under a health flexible spending arrangement.

Use the section below to upload your “Request for Treatment as an Assistance Eligible Individual” form.  If you have not yet elected COBRA, you must also upload your “COBRA Continuation Coverage Election Form (for individuals not currently on COBRA)“.

Fields below marked with an asterisk (*) are required. You may send files up to 18 MB in size, in the following formats: Thank you!

Image Formats: JPEG, JPG, GIF, PNG, BMP
Portable Document Format (PDF)

Use the “Browse” buttons to select your file for upload. Once you have attached the files you wish to upload, click the “Submit” button to complete your submission.