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CMS (Centers for Medicare & Medicaid Services) - COBRA Subsidy Denial Appeal Application Form

If you believe you are entitled to the premium assistance, you may request that either CMS or the DOL review your case. Each is accepting a separate review form. The CMS application should be used if you were employed by a public sector government employer or a private sector employer with fewer than 20 employees in states with "mini-COBRA" laws. The CMS form is available on Discovery's site.

If you were employed by a private sector employer with 20 or more employees, see the DOL Appeal Form found on our web site.

For more information about the COBRA continuation coverage laws administered by CMS and DOL, visit http://www.continuationcoverage.net/premium-assistance.html.

Form Type: Enrollment
Categories: COBRA

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