HMSA s. COBRA Assist INSTRUCTION GUIDE C ONSOLIDATED O MNIBUS B UDGET R ECONCILIATION A CT

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1 HMSA s COBRA INSTRUCTION GUIDE

2 To assist employers in meeting their obligations under the final federal COBRA regulations, HMSA s COBRA contains sample notices that incorporate the new requirements. As a reminder, HMSA is not the employer/plan administrator (plan administrators are typically the employer) and therefore does not distribute COBRA notices required to be furnished by employers/plan administrators. Upon request, however, we can assist you with monthly billings, dues collection, and tracking COBRA coverage periods. The U.S. Department of Labor (DOL) Employee Benefits Security Administration (EBSA) finalized regulations relating to COBRA continuation coverage notices. The regulations set minimum standards for timing and content of the notices, include model notices, and mandate the furnishing of two additional notices. The final rules apply to notice obligations in connection with the first plan year that begins after November 26, Highlights of the Final Rule: General Notice. Employers/plan administrators must provide covered employees and spouses a general notice that informs individuals of their COBRA rights and employer notice requirements. The general notice must normally be provided within 90 days from the date the employee or spouse first becomes covered under the group health plan, and must contain information specified in the regulations. This includes, but is not limited to, the following: The name, address and telephone number of party or parties from whom additional information about the plan and continuation coverage can be obtained; A general description of the continuation coverage under the plan, including the maximum period for which continuation coverage may be available, when and under what circumstances coverage may be extended, and the plan s requirements applicable to the payment of premiums; and An explanation of the plan s requirements regarding the responsibility of the employee or covered dependents to notify the employer/plan administrator of certain events that may qualify the individual for continuation coverage, and a description of the plan s procedures for providing such notice. Employee and Qualified Beneficiary Notice. Employees and their dependents who are eligible for COBRA coverage (generally referred to as qualified beneficiaries ) must notify employers/plan administrators of a divorce or legal separation, or where a dependent will no longer be eligible for coverage under the health plan. These events are generally referred to as qualifying events. Qualified beneficiaries must also notify

3 COBRA the employer/plan administrator of the occurrence of second qualifying events and Social Security Administration disability determinations and terminations. Employers must establish reasonable procedures for qualified beneficiaries to provide such notice. Employer Obligations. Employers must notify plan administrators within 30 days of an employee s termination of employment or reduction in an employee s hours in the following instances: when the employee is no longer eligible for coverage, the employee s death, upon the employee s entitlement to Medicare, or upon the employer s commencement of a bankruptcy proceeding. Employer/Plan Administrator Obligations. In addition to furnishing the general notice described above, plan administrators must also furnish qualified beneficiaries with an election notice no later than 14 days after receiving notice from the employer, employee, or spouse, that a qualifying event has occurred. If the employer and the plan administrator are one and the same, notice must be provided within 44 days from the date of the qualifying event or from when coverage ends. If the employer/plan administrator determines that an individual is not eligible for COBRA continuation coverage, or extended COBRA continuation coverage after the occurrence of a second qualifying event, the employer/plan administrator must notify the affected individual of this within 14 days after receiving the notice. Employers/plan administrators must also notify qualified beneficiaries receiving COBRA continuation coverage of any termination of coverage that is earlier than the applicable maximum coverage period, such as when the employer ends group health coverage for all its employees or when the required premium is not paid in a timely manner. The notice of early termination must be provided as soon as possible after the termination decision has been made. Model Notices. The final rule includes a model general notice and a model election notice. If you intend to utilize the model notices, you should customize it so that it applies to your employer group health plan. The model notices, which are appended to the final rule, can be found on the DOL s website at The information provided herein is intended to be a summary of the final rules. It is not intended to constitute legal advice. Employers should consult with their own legal counsel for detailed information regarding the final rules. 1

4 HMSA s COBRA Program contains the following: Summary of Selected COBRA Provisions...4 The Summary of COBRA Provisions outlines employers COBRA responsibilities, the number of months you re required to continue coverage for employees and their dependents, terms of continuation, reasons for termination of coverage, etc. Employer Responsibilities Under COBRA and Services Provided by HMSA... 6 This document explains the types of notices employers are required to issue and outlines services provided by HMSA. COBRA Checklist for Employers... 7 Use this checklist to assist in meeting your COBRA responsibilities. COBRA Enrollment Form (Sample 1)... 8 Use this form to notify HMSA of employees or dependents who elect continued coverage. Instructions for completing the form are included on the back of the form. General Notice of COBRA Continuation Coverage Rights (Sample 2)... 9 Federal law requires employers to provide all employees and their dependents with a general notice informing them of their COBRA rights. Before using the sample document, be sure to review and revise the enclosed sample general notice to be consistent with your procedures. COBRA Continuation Coverage Election Notice (Sample 3A)...15 COBRA Continuation Coverage Election Form (Sample 3B)...17 Important Information About Your COBRA Continuation Coverage Rights (Sample 3C)...19 An election notice (3A) must be provided when a covered employee has a qualifying event (i.e., termination of employment, reduction of hours, divorce, etc.). The election form (3B) and Important Information About COBRA Continuation Coverage Rights (3C) must also be provided with this election notice. Before using the sample documents, be sure to review and revise the enclosed sample election notice and election form to be consistent with your plan s procedures. Letter to Those Who Elect COBRA (Sample 4) After you notify HMSA of those who elect COBRA continuation coverage, HMSA will send this letter to explain our billing procedures and situations that would result in termination of continued coverage. 2

5 COBRA Reasonable Procedures for Qualified Beneficiaries (Sample 5) Qualified beneficiaries must notify plan administrators or employers of a qualifying event, a second qualifying event or where the Social Security Administration determines disability. These procedures must be provided to employees so qualified beneficiaries can provide such notice. Before using the sample document, be sure to review and revise it to be consistent with your plan s procedures. Notice of Unavailability (Sample 6) If it is determined that an individual is not eligible for COBRA continuation coverage, or extended COBRA continuation coverage after the occurrence of a second qualifying event, the employer/plan administrator must notify the affected individual of this within 14 days after receiving the election notice. Notice of Early Termination (Sample 7A) Employer/plan administrator must also notify qualified beneficiaries receiving COBRA continuation coverage of any termination of coverage that is earlier than the applicable maximum coverage period. The notice of early termination must be provided as soon as possible after the termination decision has been made. Cancellation Notice to Member (Sample 7B) HMSA will notify members of any termination of coverage that is earlier than the applicable maximum coverage period, such as when the employer ends group health coverage for all its employees or when the required premium is not paid in a timely manner. Group Billing (Sample 8) For tracking purposes, you will receive a monthly letter that will list all employees who have elected to continue coverage through COBRA. In addition, to assist you with complying with meeting the notice of early termination requirement under COBRA, we will inform you when COBRA coverage terminates for any individual prior to their allowed period of coverage. Employee Billing Card (Sample 9) Employees and/or their dependents who have elected coverage under COBRA will receive a monthly post card billing similar to this one. This billing includes the member s monthly premiums plus a 2 percent administrative fee as permitted by law. A 50 percent higher premium is permitted by law from the 19th to the 29th month for disabled individuals. We strongly recommend that you discuss your individual COBRA administration needs with your legal counsel. If you have questions about how to use the materials in this COBRA Program, please contact your HMSA Group Representative at Neighbor Island residents, please contact the HMSA office nearest you. 3

6 Summary of Selected COBRA Provisions This summary provides information that affects employers subject to COBRA. An employer generally is subject to COBRA if it sponsors a group health plan and employed at least 20 employees on half the working days of the previous calendar year. Employer Group Insurance Continuation Option Employer-based health plans, including those for retirees, are required to offer covered individuals an opportunity to continue coverage under their group health plans after their coverage would normally expire. A. Qualified Beneficiaries A qualified beneficiary includes the employee, his/her spouse, and dependent children who are covered by the employee s health plan on the day before a COBRA qualifying event occurs. In certain cases, a retired employee, the retired employee s spouse, and the retired employee s dependent children may be qualified beneficiaries. Newborns of, and a newly adopted child placed for adoption with, an individual on COBRA continuation coverage will also be treated as qualified beneficiaries. B. Qualifying Events and Continuation Periods A continuation period of 18 months is required for employees and their dependents who lose coverage through the following qualifying events: Reduction in the employee s work hours which would result in loss of health care coverage. Voluntary or involuntary termination of the employee s employment for any reason other than gross misconduct. The above continuation period can be extended for an additional 11 months for a total of 29 months when a qualified beneficiary is determined, by the Social Security Administration, to have been disabled during the first 60 days of COBRA coverage. Additionally, the 18 month continuation period may be extended in the event of a second qualifying event. A continuation period of 36 months is required for the covered employees spouse and/or dependents who lose coverage through the following qualifying events: Death of the covered employee Legal separation or divorce from covered employee Covered employee becomes entitled to Medicare Covered child loses coverage because of their age C. Terms for Continuation Qualified beneficiaries may be charged a monthly premium, not exceeding 102 percent of the total monthly cost (or 150 percent after the 18th month if coverage is extended as a result of disability). The terms of the plan, as well as conversion plan options, must be the same as those provided to similarly-situated employees. D. Notice Requirements General Notice. Employers must provide written notice of continuation coverage rights to employees and their spouses when plan coverage starts. The general notice must generally be provided within 90 days from the date the employee or spouse first becomes covered under the group health plan, and must contain information specified in the regulations. Attached as Sample 2 is a form general 4

7 COBRA notice for your use. Election Notice. Plan administrator/employer must furnish qualified beneficiaries with an election notice no later than 14 days after receiving notice from the employer, employee or spouse that a qualifying event has occurred. In cases of qualifying events triggered by a termination of employment or reduction in hours, the employer must notify the plan administrator within 30 days of a qualifying event. If the employer also serves as the plan administrator, the employer/plan administrator has 44 days after the loss of coverage to provide the election notice. Qualified beneficiaries eligible for continuation coverage must be provided 60 days to elect this coverage, beginning on the date plan coverage would terminate or on the date the election notice is sent, whichever is later. HMSA will not provide COBRA continuation coverage if continuation election notices are not provided by the employer/plan administrator to HMSA within one business day after the expiration of the qualified beneficiary s election period. Reasonable Procedures for Qualified Beneficiaries. Qualified beneficiaries must notify the employer/plan administrator of a qualifying event. Group health plans must establish reasonable procedures for qualified beneficiaries to provide such notice. Sample 5 includes model reasonable procedures. You should customize these procedures to reflect your practices. These procedures should be reflected in the general notice, the election notice and in your Plan s Summary Plan Description. Notice of Ineligibility. In addition to furnishing the general notice described above, if the employer/ plan administrator determines that an individual is not eligible for COBRA continuation coverage, or extended COBRA continuation coverage after the occurrence of a second qualifying event, the employer/plan administrator must notify the affected individual of this within 14 days after receiving the election notice. Attached as Sample 6 is a form for your use in these situations. Notice of Early Termination. Employers/plan administrators must also notify qualified beneficiaries receiving COBRA continuation coverage of any termination of coverage that is earlier than the applicable maximum coverage period, such as when the employer ends group health coverage for all its employees or when the required premium is not paid in a timely manner. The notice of early termination must be provided as soon as possible after the termination decision has been made. Attached as Sample 7A is a form for your use in these situations. E. Termination of Coverage The employer can terminate coverage prior to the end of the 18, 29 or 36 month period when: All health plans provided to all employees are cancelled.* The qualified beneficiary does not pay the premium by the billing due date (including grace period). After electing COBRA, the qualified beneficiary becomes covered by another health plan that will not subject the beneficiary to any pre-existing condition exclusions. After electing COBRA, the qualified beneficiary becomes enrolled in Medicare. After receiving an extension of COBRA coverage as a result of a disability determination from the Social Security Administration, the Social Security Administration determines that the qualified beneficiary is no longer disabled. * The Hawaii Prepaid Health Care Act requires employers to maintain health care coverage for employees who have worked 20 hours or more for four consecutive weeks. F. Penalties Failure to meet the continuation coverage requirements could result in federal penalties, including a $110 per day per violation excise tax imposed on the employer and other responsible administrators for each qualified beneficiary during the noncompliance period, up to a $500,000 maximum or 10 percent of the aggregate health care costs during the previous year, whichever is less. 5

8 Employer Responsibilities Under COBRA Employers/Plan Administrators must: notify employees and their spouses of COBRA options at the time they first become eligible for the company s group health care plan. notify affected individuals of COBRA rights no later than 14 days after coverage is lost because of a qualifying event (termination, reduction in hours, divorce or legal separation, death of employee, etc.). If the plan administrator and employer are one and the same, notice in certain instances must be provided within 44 days from the date of the qualifying event or from when coverage ends. notify HMSA of individuals electing extended COBRA coverage no later than one business day following the expiration of the time for the individual to elect to extend their coverage (must be within 60 days of cancellation of the individual s group plan coverage or date Notification of COBRA Election form is sent, whichever is later). notify COBRA beneficiaries of health plan changes as they occur and of their options during the annual Open Enrollment period. inform individuals when they are not eligible for COBRA coverage. notify COBRA beneficiaries of any early termination of COBRA coverage. Services Provided by HMSA HMSA will provide the following services: Monthly billing of COBRA premiums COBRA premium collection Account maintenance and reconciliation Tracking length of COBRA period Claims payment Customer service for benefit and claims inquiries Ongoing updates to employers regarding COBRA clarifications and amendments 6

9 COBRA COBRA Checklist for Employers Below is a checklist of some of the actions you should take to ensure your company is complying with COBRA laws: When Employee Commences Employment COBRA General Notice. Provide the covered employee and spouse with the general notice within 90 days of coverage under group s health plan. Have your employee (as well as their spouses) sign the COBRA general notice to indicate that they have received the notice, which advises them of their rights to continuation coverage. File the signed forms in the employee s personnel file. Forms should be kept for 6 years after employment ceases. When a Qualifying Event Occurs (i.e., termination of employment, reduction of hours, divorce) Notice to Plan Administrator. Inform the plan administrator within 30 days of a qualifying event. (In most instances, the employer is the plan administrator.) COBRA Election Notice. A plan administrator has 14 days to provide an election notice to the covered employee and spouse. In cases in which the qualifying event is the termination of employment or reduction in hours, and the employer serves as plan administrator, provide an election notice within 44 days from the date of the qualifying event or from when coverage ends. Notices should be sent to the qualified beneficiary s last known address and must be sent to the enrollee s spouse as well (but one election notice is allowed where qualified beneficiary and spouse reside at the same address). Notice of Ineligibility for COBRA. If an individual elects COBRA but it is determined that he/she is ineligible for coverage, provide the individual with a notice of ineligibility for COBRA advising them of the reason they are ineligible for COBRA continuation coverage. Notice of Early Termination of COBRA. If COBRA continuation coverage ends prior to the period allowed under statute, inform the COBRA enrollee of the reason for the early termination, the date of termination, and conversion options. Keep a file of your compliance efforts (i.e., training, COBRA procedures) in case you need to provide documentation. THIS PROTECTION IS VERY IMPORTANT FOR YOU! Keep a file indicating your compliance with notification requirements (i.e., copies of the individual s COBRA election form, copy of stamped envelope, and HMSA s monthly group billing that HMSA will provide to you listing those with COBRA). Open Enrollment Periods During Open Enrollment periods, provide COBRA beneficiaries with the same health plan information and opportunities as those available to your active employees. Summary Plan Descriptions (SPDs) and Summary of Material Modifications (SMMs) Provide revised SPDs (or SMMs) to qualified beneficiaries who are receiving COBRA continuation coverage. There may be additional actions that an employer should take to ensure compliance with COBRA. Employers should consult with their legal counsel for more information. 7

10 COBRA ASSIST ENROLLMENT FORM To: FROM: ADDRESS: Hawaii Medical Service Association Membership Service Department P.O. Box 860 Honolulu, Hawaii Telephone: HMSA Number (Present or Former) Name of Eligible Employee or Dependent* (Name of Company or Group) TOTAL Monthly Rate or Amount Being Remitted Qualifying Event Membership Termination Date INSTRUCTIONS FOR NOTIFYING HMSA ON COBRA ASSIST ENROLLMENT FORM HMSA Number (Present or Former) Provide the complete 13-digit membership number belonging to the employee. (R ) Name of Eligible Employee or Dependent List the individual who has elected extended group coverage under an HMSA plan, e.g., employee, spouse, or dependent. Monthly Rate or Amount Being Remitted If applicable, indicate the amount being remitted with this COBRA Enrollment Form. Qualifying Event Describe which event qualifies the individual for extended coverage under COBRA, e.g., termination, reduction in work hours, layoff for economic reasons, death of employee, divorce or legal separation, employee covered under Medicare, or dependent too old to be covered under family plan. Membership Termination Date Include the date that the individual s group coverage ended or will end. Date Election Form Sent Indicate the date Notification of COBRA Election form was mailed. COBRA Election Date Include the date that the individual elected to extend his or her coverage under COBRA. **Other Carrier Indicate name of carrier switching from. A new HMSA enrollment form is required if coming from another carrier and must accompany the Cobra enrollment form. Billing Address and Remarks Include the billing address of the individual. Also use this section to report any information pertinent to the COBRA enrollee. DATE: GROUP/SUBGROUP NUMBER: PHONE NUMBER: Date Election Form Sent COBRA Election Date Other Carrier** Billing Address and Remarks *List spouse or dependent s name here if application is being made in their own name. Signed **Refer to additional instructions on back of form. (Report must be signed by Group Leader or authorized person) COBRA ENROLL- 9:04 Sample 1 See reverse side for enrollment instructions. Remember all items on this form must be completed or COBRA enrollment may be delayed. COBRA enrollment is subject to meeting eligibility requirements. 8

11 COBRA For use by single-employer group health plans Sample 2 GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS **CONTINUATION COVERAGE RIGHTS UNDER COBRA** Introduction You are receiving this notice because you have recently become covered under a group health plan (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage. For additional information about your rights and obligations under the Plan and under federal law, you should review the Plan s Summary Plan Description or contact the Plan Administrator (typically, your employer). What is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a qualifying event. Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a qualified beneficiary. You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens: Your hours of employment are reduced, or Your employment ends for any reason other than your gross misconduct. If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens: Your spouse dies; Your spouse s hours of employment are reduced; Your spouse s employment ends for any reason other than his or her gross misconduct; Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or You become divorced or legally separated from your spouse. 9

12 Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happens: The parent-employee dies; The parent-employee s hours of employment are reduced; The parent-employee s employment ends for any reason other than his or her gross misconduct; The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); The parents become divorced or legally separated; or The child stops being eligible for coverage under the Plan as a dependent child. If the Plan provides retiree health coverage, the following also applies: Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to your Employer, and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary with respect to the bankruptcy. The retired employee s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. When is COBRA Coverage Available? The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the employer/plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, the employee s becoming entitled to Medicare benefits (under Part A, Part B, or both), or commencement of a proceeding in bankruptcy with respect to the employer (in the case where a Plan provides retiree health coverage), the employer must notify the Plan Administrator of the qualifying event. You Must Give Notice of Some Qualifying Events Sample 2 For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child s losing eligibility for coverage as a dependent child), you must notify the employer/plan Administrator within 60 days after the qualifying event occurs. You must provide this notice in writing to the Plan contact indicated at the end of this general notice. The notice must indicate the name(s) of the affected individual(s), the date of the qualifying event, and a short description of the facts related to the qualifying event. If the qualifying event is a divorce or legal separation, you are also required to provide a copy of the divorce decree or separation agreement. How is COBRA Coverage Provided? Once the employer/plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. 10

13 COBRA Sample 2 COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee s becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a dependent child s losing eligibility as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee s hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended. Disability extension of 18-month period of continuation coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the employer/plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60 th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. You must provide the employer/plan Administrator written notice of the disability within 60 days of the later of (i) the qualifying event, (ii) the disability determination, or (iii) the date on which you would otherwise lose your coverage. The notice must indicate the name of the affected individual, the date of the qualifying event, and include a copy of the Social Security Administration s decision. If the Social Security Administration later determines that you are no longer disabled, you must provide the employer/plan Administrator with written notice within 30 days of the Social Security Administration s determination. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s website.) 11

14 Instructions for General Notice of COBRA Continuation Coverage Rights 1. Enter plan contact Information as indicated. Keep Your Plan Informed of Address Changes In order to protect your family s rights, you should keep the employer/plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the plan administrator. Plan Contact Information Employer Group or Plan Administrator: Contact: Address: Phone Number: 1 Sample 2 12

15 COBRA Have your employees and their spouses sign and date this Acknowledgement of Receipt. Keep this document with your files to demonstrate your company s compliance with COBRA laws. Sample 2 ACKNOWLEDGMENT OF RECEIPT By signing below, I acknowledge I have received the General Notice of COBRA Continuation Coverage Rights notifying me of my rights to extend my group plan coverage. Employee s Signature Date Print Employee s Name Spouse s Signature Date Print Spouse s Name 13

16 Instructions for COBRA Continuation Coverage Election Notice 1. Enter the date of the notice. 2. Enter the name of the group health plan. 3. Enter the name of the employer/plan administrator. 4. Identify the qualified beneficiary(ies) by name or status. 5. Enter the date coverage will end. 6. Check the applicable qualifying event. 7. Enter either 18 or 36 depending on the qualifying event. 8. Check the applicable qualified beneficiary category. You may add the name(s) of the qualified beneficiary(ies) next to the appropriate category. 9. Enter the start date for COBRA coverage. 10. Enter the end date for COBRA coverage based on the length of coverage applicable for the qualifying event. 11. Enter the date the current COBRA premium will end. 12. Enter the applicable premiums that will be required for each option per month of coverage. Please contact your HMSA Marketing representative for cost information. 13. Enter the Plan contact information as indicated. 14

17 COBRA For use by single-employer group health plans Sample 3A 1 COBRA CONTINUATION COVERAGE ELECTION NOTICE Date: Name of Group Health Plan: 2 3 Employer/Plan Administrator: 4 Dear : This notice contains important information about your right to continue your health care coverage in the above group health plan (the Plan). Please read the information contained in this notice very carefully. To elect COBRA continuation coverage, follow the instructions on the next page to complete the enclosed Election Form and submit it to us. 5 If you do not elect COBRA continuation coverage, your coverage under the Plan will end on due to the following: End of employment Reduction in hours of employment 6 Death of Employee Divorce or legal separation Entitlement to Medicare Loss of dependent child status Each person ( qualified beneficiary ) in the category (ies) checked below is entitled to elect COBRA continuation coverage, which will continue group health care coverage under the Plan for up to 7 months: Employee or former employee 8 Spouse or former spouse Dependent child(ren) covered under the Plan on the day before the event that caused the loss of coverage Child who is losing coverage under the Plan because he or she is no longer a dependent under the Plan If elected, COBRA continuation coverage will begin on 9 and can last until. 10 COBRA continuation coverage cost through 11 is indicated below. Thereafter, your cost may change at the same time premium changes are made to the Plan for all active employees. Single $ 2-Party $ Family $ 12 You do not have to send any payment with the Election Form. Important additional information about payment for COBRA continuation coverage is included in the pages following the Election Form. If you have any questions about this notice or your rights to COBRA continuation coverage, you should contact the person indicated below: Employer or Plan Administrator: 13 Contact: Address: Phone Number: 15

18 Instructions for COBRA Continuation Coverage Election Form 1. Enter the name of the employer/plan Administrator and contact information as indicated. 2. Enter the date the Election Form must be post-marked by based on 60 days from the date of the election notice. 3. If the qualified beneficiary will be permitted to fax or hand-deliver election notice, indicate here. Be sure to include the date the election notice must be received by if faxed or hand-delivered. 4. Enter the name of the group health plan. 16

19 COBRA For use by single-employer group health plans Sample 3B Employer or Plan Administrator: Contact: Address: Phone Number: 1 COBRA CONTINUATION COVERAGE ELECTION FORM INSTRUCTIONS: To elect COBRA continuation coverage, complete this Election Form and return it to us. Under federal law, you must have 60 days after the date of the COBRA Continuation Coverage Election Notice to decide whether you want to elect COBRA continuation coverage under the Plan. Send completed Election Form to the above contact and address. This Election Form must be completed and returned by mail. It must be post-marked no later than If you do not submit a completed Election Form by the due date shown above, you will lose your right to elect COBRA continuation coverage. If you reject COBRA continuation coverage before the due date, you may change your mind as long as you furnish a completed Election Form before the due date. However, if you change your mind after first rejecting COBRA continuation coverage, your COBRA continuation coverage will begin on the date you furnish the completed Election Form. Read the important information about your rights included in the pages after the Election Form. I (We) elect COBRA continuation coverage in the (the Plan) as indicated below: 4 Name Birth Date Relationship to Employee SSN (or other identifier) Signature Print Name Date Relationship to individual(s) listed above Print Address Telephone Number 17

20 Instructions for Important Information About Your COBRA Continuation Coverage Rights 1. Enter the name of the group health plan. 2. Enter the name of the employer/plan Administrator and contact information as indicated. 18

21 COBRA For use by single-employer group health plans Sample 3C 1 Name of Group Health Plan: Employer or Plan Administrator: 2 Contact: Address: Phone Number: IMPORTANT INFORMATION ABOUT YOUR COBRA CONTINUATION COVERAGE RIGHTS What is continuation coverage? Federal law requires that most group health plans (including this Plan) give employees and their families the opportunity to continue their health care coverage when there is a qualifying event that would result in a loss of coverage under an employer s plan. Depending on the type of qualifying event, qualified beneficiaries can include the employee (or retired employee) covered under the group health plan, the covered employee s spouse, and the dependent children of the covered employee. Continuation coverage is the same coverage that the Plan gives to other participants or beneficiaries under the Plan who are not receiving continuation coverage. Each qualified beneficiary who elects continuation coverage will have the same rights under the Plan as other participants or beneficiaries covered under the Plan, including open enrollment and special enrollment rights. How long will continuation coverage last? In the case of a loss of coverage due to end of employment or reduction in hours of employment, coverage generally may be continued only for up to a total of 18 months. In the case of losses of coverage due to an employee s death, divorce or legal separation, the employee s becoming entitled to Medicare benefits or a dependent child ceasing to be a dependent under the terms of the plan, coverage may be continued for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee s hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. This notice shows the maximum period of continuation coverage available to the qualified beneficiaries. Continuation coverage will be terminated before the end of the maximum period if: any required premium is not paid in full on time, a qualified beneficiary becomes covered, after electing continuation coverage, under another group health plan that does not impose any pre-existing condition exclusion for a pre-existing condition of the qualified beneficiary, a covered employee becomes entitled to Medicare benefits (under Part A, Part B, or both) after electing continuation coverage, or the employer ceases to provide any group health plan for its employees. Continuation coverage may also be terminated for any reason the Plan would terminate coverage of a participant or beneficiary not receiving continuation coverage (such as fraud). If you are eligible for less than 36 months of coverage, you may become eligible for an extended period of coverage. Please read the following section to see if you qualify. How can you extend the length of COBRA continuation coverage? If you elect continuation coverage, an extension of the maximum period of coverage may be available if a qualified beneficiary is disabled or a second qualifying event occurs. You must notify the above indicated contact who is responsible for COBRA administration of a disability or a second qualifying event in order to extend the period of 19

22 Sample 3C continuation coverage. Failure to provide notice of a disability or second qualifying event may affect the right to extend the period of continuation coverage. (*Note: HMSA is not responsible for COBRA administration.) Disability An 11-month extension of coverage may be available if any of the qualified beneficiaries is determined by the Social Security Administration (SSA) to be disabled. The disability has to have started at some time before the 60 th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. You must notify your employer or Plan Administrator in writing within 60 days of the later of (i) the determination of disability, (ii) the qualifying event, or (iii) the date on which your coverage would otherwise terminate. The notice must indicate the name of the affected individual, the date of the qualifying event, and a copy of the Social Security Administration s decision. Each qualified beneficiary who has elected continuation coverage will be entitled to the 11- month disability extension if one of them qualifies. If the qualified beneficiary is determined by SSA to no longer be disabled, you must notify the Plan of that fact within 30 days after SSA s determination. Second Qualifying Event An 18-month extension of coverage will be available to spouses and dependent children who elect continuation coverage if a second qualifying event occurs during the first 18 months of continuation coverage. The maximum amount of continuation coverage available when a second qualifying event occurs is 36 months. Such second qualifying events may include the death of a covered employee, divorce or separation from the covered employee, the covered employee s becoming entitled to Medicare benefits (under Part A, Part B, or both), or a dependent child s ceasing to be eligible for coverage as a dependent under the Plan. These events can be a second qualifying event only if they would have caused the qualified beneficiary to lose coverage under the Plan if the first qualifying event had not occurred. You must notify your employer or Plan Administrator in writing within 60 days after a second qualifying event occurs if you want to extend your continuation coverage. The notice should include the name of the affected individual, the date of the second qualifying event and a brief description of the facts of the second qualifying event. If the second qualifying event is a divorce or legal separation, the notice must include a copy of the divorce decree or separation agreement, as applicable. How can you elect COBRA continuation coverage? To elect continuation coverage, you must complete the Election Form and furnish it according to the directions on the form. Each qualified beneficiary has a separate right to elect continuation coverage. For example, the employee s spouse may elect continuation coverage even if the employee does not. Continuation coverage may be elected for only one, several, or for all dependent children who are qualified beneficiaries. A parent may elect to continue coverage on behalf of any dependent children covered at the time of the qualifying event, and special rights apply to children born or adopted to an employee who experiences a qualifying event. The employee or the employee s spouse can elect continuation coverage on behalf of all of the qualified beneficiaries. In considering whether to elect continuation coverage, you should take into account that a failure to continue your group health coverage will affect your future rights under federal law. First, you can lose the right to avoid having pre-existing condition exclusions applied to you by other group health plans if you have more than a 63-day gap in health coverage, and election of continuation coverage may help you not have such a gap. Second, you will lose the guaranteed right to purchase individual health insurance policies that do not impose such pre-existing condition exclusions if you do not get continuation coverage for the maximum time available to you. Finally, you should take into account that you have special enrollment rights under federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse s employer) within 30 days after your group health coverage ends because of the qualifying event listed above. You will also have the same special enrollment right at the end of continuation coverage if you get continuation coverage for the maximum time available to you. How much does COBRA continuation coverage cost? Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. The amount a qualified beneficiary may be required to pay may not exceed 102 percent (or, in the case of an extension of continuation coverage due to a disability, 150 percent) of the cost to the group health plan (including both employer and employee contributions) for coverage of a similarly situated plan participant or beneficiary who is not receiving continuation coverage. The required payment for each continuation coverage period for each option is described in this notice. 20

23 COBRA Sample 3C If employees are eligible for trade adjustment assistance, the following information applies. The Trade Act of 2002 created a new tax credit for certain individuals who become eligible for trade adjustment assistance and for certain retired employees who are receiving pension payments from the Pension Benefit Guaranty Corporation (PBGC) (eligible individuals). Under the new tax provisions, eligible individuals can either take a tax credit or get advance payment of 65% of premiums paid for qualified health insurance, including continuation coverage. If you have questions about these new tax provisions, you may call the Health Coverage Tax Credit Customer Contact Center toll-free at TTD/TTY callers may call toll-free at More information about the Trade Act is also available at When and how must payment for COBRA continuation coverage be made? First payment for continuation coverage If you elect continuation coverage, you do not have to send any payment with the Election Form. However, you must make your first payment for continuation coverage not later than 45 days after the date of your election. (This is the date the election notice is post-marked, if mailed.) If you do not make your first payment for continuation coverage in full not later than 45 days after the date of your election, you will lose all continuation coverage rights under the Plan. You are responsible for making sure that the amount of your first payment is correct. You may contact the Plan Administrator or your employer to confirm the correct amount of your first payment. Periodic payments for continuation coverage After you make your first payment for continuation coverage, you will be required to make periodic payments for each subsequent coverage period. The amount due for each coverage period for each qualified beneficiary through the end of the current contract period with HMSA is shown in this notice. The periodic payments can be made on a monthly basis. Under the Plan, each of these periodic payments for continuation coverage is due on the first of each month. If you make a periodic payment on or before the first day of the coverage period to which it applies, your coverage under the Plan will continue for that coverage period without any break. HMSA will send periodic notices of payments due for these coverage periods. Grace periods for periodic payments Although periodic payments are due on the dates shown above, you will be given a grace period of 30 days after the first day of the coverage period to make each periodic payment. Your continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment. However, if you pay a periodic payment later than the first day of the coverage period to which it applies, but before the end of the grace period for the coverage period, your coverage under the Plan will be suspended as of the first day of the coverage period and then retroactively reinstated (going back to the first day of the coverage period) when the periodic payment is received. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated. If you fail to make a periodic payment before the end of the grace period for that coverage period, you will lose all rights to continuation coverage under the Plan. Your first payment for continuation coverage should be sent to: HMSA P. O. Box 4720 Honolulu, HI All periodic payments for continuation coverage should be sent to: HMSA P. O. Box Honolulu, HI For more information This notice does not fully describe continuation coverage or other rights under the Plan. More information about continuation coverage and your rights under the Plan is available in your summary plan description or from the Plan Administrator or your employer. 21

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