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.
25ET-2128
Brochure
Active Employee /
Retiree /
Local Employer
As a participant in this health insurance program, you have certain rights and responsibilities. By becoming familiar with them, you will be able to make the most of your health care.
Program Option
Local Deductible Health Plan (PO14) & Supplemental Benefits
Local Deductible Health Plan with Uniform Dental (PO4) & Supplemental Benefits
Local Health Plan (PO16) & Supplemental Benefits
Local Health Plan with Uniform Dental (PO6) & Supplemental Benefits
Local High Deductible Health Plan (PO17) & Supplemental Benefits
Local High Deductible Health Plan with Uniform Dental (PO7) & Supplemental Benefits
Local Traditional Health Plan (PO12) & Supplemental Benefits
Local Traditional Health Plan with Uniform Dental (PO2) & Supplemental Benefits
State Employee and Retiree Health Plan & Supplemental Benefits