CurrentFlorida BluePolicy N/A

Continuation of Coverage Qualifying Event Form

This document is a Florida Blue form to report COBRA qualifying events for group members and dependents and to collect required information to administer continuation of coverage.

Policy Summary

PayerFlorida Blue

PolicyContinuation of Coverage Qualifying Event Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionReturn completed Qualifying Event form to Florida Blue at the address or phone number shown to initiate continuation of coverage processing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18 monthsstandard continuation period for certain qualifying events

36 monthscontinuation period for other qualifying events

1-4dependent entry blocks on form

1-3contact methods requested

Continuation Periods and Qualifying Events

Continuation Periods by Qualifying Event

Continuation of coverage durations and qualifying event categories to be used when determining COBRA eligibility:

ALL of the following

Qualifying event is one of: Employee retirement; Employee's reduction in hours; Employee's resignation; Employee's layoff
Continuation period: 18 months

ALL of the following

Qualifying event is one of: Employee's involuntary termination; Employee begins leave of absence
Continuation period: 18 months

Policy Summary

PayerFlorida Blue

PolicyContinuation of Coverage Qualifying Event Form

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionReturn completed Qualifying Event form to Florida Blue at the address or phone number shown to initiate continuation of coverage processing.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Key Definitions

Qualifying Event

DefinitionQualifying Event: an event that causes loss of coverage and may trigger continuation/COBRA rights (examples listed on the form).

Examples — 18-month continuationEmployee retirement; reduction in hours; resignation; layoff; involuntary termination; begin leave of absence (events listed as qualifying events that trigger 18 months of continuation).

Examples — 36-month continuationDivorce/legal separation; ineligibility of dependent child; covered employee/retiree becomes entitled to Medicare; death of covered employee/retiree; loss of coverage due to employer bankruptcy proceedings (events listed as qualifying events that trigger 36 months of continuation).

Form usageThe form provides checkboxes to indicate the type of qualifying event and the applicable continuation period (18 or 36 months).

Qualified Beneficiary: employee or dependent who experienced the qualifying event

DefinitionQualified Beneficiary: the employee or dependent who experienced the qualifying event and may be eligible for continuation coverage.

Required identifiersForm requests Qualified Beneficiary name, Social Security Number, date of birth, home phone, gender, and address entries as applicable.

Relationship to employeeIf the Qualified Beneficiary is a dependent, the form asks for the employee's SSN and the dependent's relationship to the employee.

Second qualifying eventForm asks whether this is a second qualifying event for a dependent currently on COBRA (Yes/No).

Benefit termination dateForm requires Benefit Termination Date (cannot be prior to Qualifying Event Date).

OpenPayer

Continuation of Coverage Qualifying Event Form

Continuation Periods and Qualifying Events

Form Submission and Contact Instructions

Key Definitions