Model COBRA Subsidy Notice

This notice is only used by former State of Wisconsin employees or local government employees who participated in the Wisconsin Public Employers Group Health Insurance Program.

This is the Model Notice for COBRA Continuation Subsidy under the American Rescue Plan [ARP] Act of 2021. Employers please note that information for qualified beneficiaries must be completed. 

This unlocked Word document has space at the top for you to print on your own letterhead; please also complete all necessary information throughout. This must be provided with the Request for Treatment as an Assistance Eligible Individual (ET-2314).

You can see the original document here.