EXPLANATION OF USE FOR THE MODEL QUALIFIED BENEFICIARY NOTICE
This memorandum is being provided to explain the use of the Model Qualified Beneficiary Notice which is
attached hereto. By way of explanation, on May 26, 2004 the United States Department of Labor issued final
rules specifying the required content and timing of notices required by the health care continuation coverage
provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (“COBRA”). Those final rules
require that Qualified Beneficiaries provide notice to the plan if there is: (1) a divorce or legal separation, (2)
if dependants cease to be eligible under the plan, (3) when a determination of disability or change in
disability status has been made; and, (4) if there is a second qualifying event
The attached Model Qualified Beneficiary Notice has been prepared by Blue Cross & Blue Shield of
Mississippi as a courtesy to our customers and should be used by you as the employer or by your Plan
Administrator. However, please understand that the attached Model Qualified Beneficiary Notice is intended
to serve only as a guide to assist you in the development of your group’s Model Qualified Beneficiary
Notice. Please remember, if your group is not subject to COBRA then you will not need to utilize this
notice. Your Model Qualified Beneficiary Notice should include the name of the plan and the name, address
and telephone number of the party responsible under the plan for administering COBRA benefits, in that
connection, it will be necessary for the provided Model Qualified Beneficiary Notice to be altered to include
that information.
The Model Qualified Beneficiary Notice should be included in the plan package delivered to each employee
for the employee’s use. This Model Qualified Beneficiary Notice should be deemed timely if it is
received within 60 days of the later of (1) the date of the qualifying event, (2) the date of loss of
coverage under the plan, (3) the date the qualified beneficiary receives notice of thi