OCA's COBRA & Direct Bill Rate Renewal Form

COBRA/Direct Bill Rate Renewal Form

This online renewal form will require you to complete a few basic questions regarding your organizations benefit plans and rates for the upcoming rate cycle.
Who are you?*

I am the brokerI am the employer
Employer Name*
Please provide the "Employer/Client" Name here
Status

Submitted Renewal
Enhancements to this form went into effect on 5/26/23

Employer Contact Information
Employer Primary Contact Name

First NameLast Name
Employer Primary Contact E-mail
Primary Phone Number
Broker Contact Information
Broker Contact

First NameLast Name
Broker E-mail
Do you have updates to eligibility contact(s)?

Contacts entered in this section will be contacted for COBRA coverage related communications. The email is system-generated from OCA's COBRA system and will come from noreply.oca@wealthcarecobra.com. A contact can be the Employers, Carriers, Brokers, etc. To view a list of the different email communications, please click here.
Eligibility Contacts*

Primary Employer Contact Listed on ApplicationPrimary Broker Contact Listed on ApplicationAdd Additional Contact(s)
Additional Contacts:

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Employer Bank Name
Bank Account Number
Bank Routing Number

COBRA & Direct Billing Rate Renewal
COBRA generally applies to all private-sector group health plans maintained by employers that had at least 20 employees on more than 50 percent of its typical business days in the previous calendar year. Both full- and part-time employees are counted to determine whether a plan is subject to COBRA.
Is the employer subject to Federal COBRA or State Continuation for the plans/rates being submitted?*

Federal COBRAState ContinuationOther
Please identify the State the plans are written in below:*
Please indicate the # of COBRA/Retiree Billing benefits being added/updated:*
Note: Two medical plans will count as 2 eligible benefits
Additional COBRA Administrative Fees- Open Enrollment Material

OCA will charge the employer (or the party responsibile for paying OCA's monthly COBRA administrative fees) $3 for every 10 pages with a minimum of a $3 charge for 10 pages and under. This is a per member per packet fee.

OE Mailing Fee examples
- Less than 10 pages: $3 per packet
- 10-20: $6 per packet
- 21-30: $9 per packet
- 31-40: $12 per packet
- 41-50: $15 per packet
- 51-60: $18 per packet
- 61+: OCA will contact you for pricing
Please note that OCA will mail the open enrollment material to any existing qualified beneficary and/or COBRA participants at the time of the open enrollment submission. Open enrollment material will need to be provided by the employer for any future qualified beneficiaries that occur after this renewal submission.
Are you the billing contact for this employer?

YesNo
Employer Billing Contact Email
Please note an email notification will be sent to this employer contact informing them of the OE notice fees
Terms and Conditions

Open Enrollment Actions*

Required
COBRA Open Enrollment

Qualified beneficiaries (participants) are entitled to the same rights as active employees during open enrollment. During this time period, they have the right to change their elected benefits, add or remove dependents, and are given the same benefits/choices that similarly situated active employees have. Open enrollment must be offered to all active COBRA participants and any qualified beneficiaries. Qualified beneficiaries include individuals in their initial election period. If {employerName} has any COBRA participants and qualified beneficiaries (QB) who are eligible to elect COBRA continuation coverage, each must be given notification about open enrollment, rate changes, and benefit changes. You may send the open enrollment packets directly to any COBRA Participants or QB's or OCA can provide participants on the employer’s behalf through the participant portal.
Would you like OCA to manage the COBRA "Open Enrollment" for existing COBRA Participants and Qualified Beneficiaries?*

YesNO
Open Enrollment Start Date*

MonthDayYear
The date you want the participant to be able to participate in Open Enrollment.
Open Enrollment End Date*

MonthDayYear
The date you want the participant to no longer be able to participate in Open Enrollment.
What happens if a Participant fails to elect during Open Enrollment?

If the employer requires an "active enrollment" and the participant does not elect benefits during open enrollment, they forfeit their benefits for that plan year and will not be covered. If the employer allows for a passive enrollment, the participant can maintain their existing coverage and/or be enrolled in the default coverage option. This open enrollment set up can be identified on OCA's Rate Renewal Form.
Do you want OCA to provide existing QBs and COBRA participants with Open Enrollment Material (i.e. SPDs)?*

YesNo
Upload Open Enrollment Forms (i.e. SPD/SBC)*

Cancelof
Do you have different COBRA eligible benefit plans/rates that are based upon employee statues, location, divisions, etc.?

YesNo

Rate Renewal Confirmation
Do you have (or have requested) a COBRA integration feed?*

YesNo
Please confirm the current EDI/Integrations platform below:*
I.e. Employee Navigator, ADP, etc.
- If you currently have a COBRA file feed integration, please ensure that you have updated all plan and rate information with with the file feed vendor. If the plan name(s) on file with OCA do not match the naming convention with the file feed vendor, OCA will not be able to process the file.
- Participants will be instructed to contact the applicable carrier(s) for any coverage related questions.
- Should you have any questions or need any additional information, please email cobra@oca125.com. You may also call OCA at 855-622-0777. We thank you for the opportunity to be of service!
Any additional comments/notes to provide?
Name of individual submitting application*

First NameLast Name
Your Email*
example@example.com
Should be Empty:

COBRA/Direct Bill Rate Renewal Form

Employer Contact Information

Broker Contact Information

New Premium Disbursement Enhancements

COBRA & Direct Billing Rate Renewal

Plan/Rate Information

Plan/Rate Information

Plan/Rate Information

Plan/Rate Information

Plan/Rate Information

Plan/Rate Information

Plan/Rate Information

Plan/Rate Information

Plan/Rate Information

Plan/Rate Information

Plan/Rate Information

Rate Renewal Confirmation