Blue Cross Termination Form
Blue Cross Information Change – Termination Form

How to terminate an employee from Anthem Blue Cross Group Health Coverage.

Canceling employees from the plan

Electronic enrollment is Small Group’s new standard to delete employees from your plan. If you have opted out of electronic enrollment, please complete section 2 of the 1-100 Small Group Information Change Form for the following:

An employee’s coverage under the plan must be canceled if:

Employment is terminated.
An eligible full-time employee changes to a part-time employee, and your plan does not cover part-time employees.
An employee is on a leave of absence (medical and/or personal) and the time period that the employer covers employees on leave has expired.
An eligible part-time employee’s work is permanently reduced to less than the minimum number of hours per week, based on whether you have elected to offer coverage for those who work 20–29 hours per week.
An eligible employee becomes ineligible by becoming seasonal, temporary, substitute or 1099.
An employee otherwise becomes ineligible to participate in the plan.
The employee no longer wants to continue federal COBRA coverage.

Please include the following information:

Employee name
Social Security number or member ID number
Updated address (if applicable)
Date of birth
Termination date (last day worked)
Request for COBRA (only complete if enrolling) or Cal-COBRA
Qualifying event for termination

Please fax termination notices to us at 1-855-750-2227 or mail them to:

Anthem Blue Cross
Small Group Services
P.O. Box 9062
Oxnard, CA 93031-9062

Or to [email protected] if you have appointed us as your broker.

Please do not include the 1-100 Small Group Information Change Form with termination information or any correspondence with your monthly payment.

You are required by law to allow eligible employees to remain on the plan until their employment is terminated. The termination will be effective the first of the month following the last day of employment. Timely notification of terminations is required to ensure that coverage does not extend beyond the month when the termination occurred and to comply with COBRA and Cal-COBRA notification requirements. When notification is delayed, we are unable to cancel coverage in a timely manner, which results in continued coverage for ineligible employees and dependents.

Due to applicable state law, retroactive plan and/or policy terminations are not allowed. When a member’s employment is terminated, the employee must be canceled from the group. Employees who elect to continue coverage under COBRA must  still be canceled from the plan. After Anthem is notified about the COBRA election, the member will be enrolled under your COBRA benefits.

You are obligated under law and by contract with Anthem to notify employees of their termination of coverage and of any rights to continue coverage. Failure to do so exposes you to liability to the employee and to Anthem. When preparing your monthly premium payment, please do not delete any premiums for canceled members. A credit for the deletion will be reflected on a future billing.

Anthem does not accept retroactive terminations.  Excerpt from 2018 Group Administrative Manual

Main Blue Cross & Related Pages

How to add a new hire, dependent, etc.

Cal-Cobra – 36 months of employer plan coverage.

ObamaCare Quotes for the terminated employee

More Blue Cross Forms on their website

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