GROUP HEALTH INSURANCE INITIAL CONTINUATION NOTIFICATION

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1 Human Resources Development 200 Bloomfield Avenue West Hartford, CT Street City, State, Zip Code Date of Notification: Coverage Effective Date: RE: GROUP HEALTH INSURANCE INITIAL CONTINUATION NOTIFICATION The office of Human Resources Development (HRD) is in receipt of your enrollment materials for participation in a University of Hartford group health and dental plans. All enrollment materials will be processed and mailed directly to the insurance carrier. You should receive confirmation of group health plan enrollment as well as identification cards within the next few weeks. Specific details regarding plan design and benefit coverage can be obtained by referring to the applicable plan document, available on-line at or upon request in HRD. This initial continuation notice outlines covered participants potential future options and, more importantly, your notification obligations under the federal Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA) should you ever lose your health coverage for certain reasons in the future. This notice applies individually to the following plan participant(s): Medical Insurance: United Healthcare Enhanced POS Dental Insurance: Aetna Freedom of Choice Please review your notification obligations and procedures, which are highlighted in this document. It is important that all covered individuals take the time to read this notice carefully and be familiar with its contents. If there is a covered dependent whose legal residence is not yours, please provide written notification to HRD by using the enclosed Address Notification Form so that a notice can be sent to them as well. If you add additional dependents to your plan in the future, notice to the covered employee and spouse/same-sex partner at this time will be deemed notification to that newly covered dependent as well. Please retain this notice in your records for future reference. Plan Administrator The Plan Administrator is the department of Human Resources Development, University of Hartford, 200 Bloomfield Avenue, West Hartford CT 06117, (860) , The Plan Administrator is responsible for administering continuation coverage under federal COBRA law. What is Continuation Coverage Under COBRA, if you lose your group health insurance because one of the below listed qualifying events occurs, covered employees and covered family members (called qualified 1 of 5

2 beneficiaries) will be offered the opportunity for a temporary extension of health insurance coverage (called continuation coverage) at the group rate, which you will be required to pay. This notice is intended to inform all covered plan participants of potential future options and obligations under the continuation coverage provisions of federal law. If an actual qualifying event occurs in the future, HRD will send you additional information and the appropriate election notice at that time. Qualifying Events for Covered Employees If you are the covered employee, you will become a qualified beneficiary and have the right to elect health plan continuation coverage if you lose your group health coverage due to a reduction in hours or termination of employment (for reasons other than gross misconduct). Qualifying Events for Covered Spouse or Same-sex Partner If you are the covered spouse or same-sex partner of an employee, you will become a qualified beneficiary and have the right to elect health plan continuation coverage if you lose group health coverage for any of the following reasons: Reduction in your spouse/same-sex partner s hours of employment or termination of your spouse/same-sex partner s employment (for reasons other than gross misconduct); Divorce or, if applicable, legal separation or dissolution of partnership from your spouse/same-sex partner; or Death of your spouse/same-sex partner. Under federal law, the term spouse does not include same-sex partners. However, the University s group health plans allow Same-sex partners to be covered by the plan. If a same-sex partner loses group health insurance as a result of one of the above listed qualified events, he/she will be offered the opportunity to continue the group health insurance as a qualified beneficiary. Qualifying Events for Covered Dependent Children If you are the covered dependent child of an employee, you will become a qualified beneficiary and have the right to elect health plan continuation coverage if you lose group health coverage for any of the following reasons: Reduction in your parent s (employee s) hours of employment or termination of your parent (employee s) employment (for reasons other than gross misconduct); Divorce or, if applicable, legal separation of your parent (employee); or You cease to be eligible for coverage as a dependent child under the terms of the health plan (i.e., no longer eligible due to age or loss of full-time student status); or Death of your parent (employee). PROTECT YOUR GROUP HEALTH INSURANCE CONTINUATION COVERAGE RIGHTS - EMPLOYEE AND QUALIFIED BENEFICIARY 60-DAY NOTIFICATION REQUIREMENT Under group health plan guidelines and federal COBRA law, the employee, spouse/same-sex partner or other eligible dependent(s) has the responsibility to notify HRD of a divorce, legal separation or a child losing dependent status under the terms of the plan. Please refer to your plan document for specific information on when a dependent ceases to be a dependent under the terms of the plan. To protect your continuation coverage rights in these situations, this notification to HRD must be made within 60 days from whichever date is later the date of the event or the date on which the health plan coverage would be lost under the terms of the plan. Procedures for making proper and timely notice are listed below. 1. Complete the enclosed Qualifying Event Notification Form. Retain a copy for your records. 2. Attach the required documentation (depending upon the qualifying event) to the notification form. 3. Mail or deliver the notification form to HRD to the address listed on the form. 2 of 5

3 4. Call HRD within 10 days to ensure the notification form has been received. If this notification is not completed according to the outlined procedures and within the required 60-day notification period, the rights to continuation coverage will be forfeited. In addition, keeping an individual covered by the group health plan beyond what is allowed by the terms of the plan may be considered insurance fraud on the part of the employee. Election Period and Coverage Once HRD learns a qualified event has occurred, HRD will notify qualified beneficiaries of their rights to elect continuation coverage. Each qualified beneficiary has independent election rights and will have 60 days to elect continuation coverage. The 60-day election window is measured from the later of the date group health plan coverage is lost due to the qualifying event or from the date of notification. This is the maximum period allowed to elect continuation coverage as the plan does not provide an extension of the election period beyond what is required by law. For each qualified beneficiary who elects group health insurance continuation coverage, coverage will begin on the date that coverage under the terms of the plan would be lost because of the qualifying event. If a qualified beneficiary does not elect continuation coverage within this election period, then rights to continue group health insurance will end and they cease to be a qualified beneficiary. If a qualified beneficiary elects continuation coverage, he/she will be required to pay the entire cost for the group health insurance, plus a 2% administrative fee. The University of Hartford is required to provide the qualified beneficiary with coverage that is identical to the coverage provided under the terms of the plan to similarly situated non-cobra participants and/or covered dependents. If coverage should change or be modified for non-cobra participants, then the change and/or modification will be made to your coverage as well. Length of Continuation Coverage 18 Months If the qualifying event causing the loss of coverage is a reduction in work hours or termination of employment (other than for reasons of gross misconduct), then each qualified beneficiary will have the opportunity to continue coverage for 18 months from the date of the qualifying event. Note one exception: If you are participating in a health care flexible spending account at the time of the qualifying event, you will only be allowed to continue the health care flexible spending account until the end of the current plan year in which the qualifying event occurs. Social Security Disability Extension The 18 months of continuation coverage can be extended for an additional 11 months of coverage, to a maximum of 29 months, for all qualified beneficiaries if the Social Security Administration determines a qualified beneficiary is disabled according to Title II or XVI of the Social Security Act on the date of the qualifying event or at any time during the first 60 days of continuation coverage. In the case of a newborn or adopted child that is added to a covered qualified beneficiary s continuation coverage, then the first 60 days of continuation coverage for the newborn or adopted child is measured from the date of birth or date of adoption. It is the qualified beneficiary s responsibility to obtain this determination from the Social Security Administration and provide a copy of this determination to HRD according to the below listed notification procedures within 60 days after the date of determination and before the original 18 months of continuation coverage expires. In general, if coverage is extended due to Social Security disability, premium rates may be raised to 150% of the applicable rate. Secondary Event Extension An extension of the original 18 months, or the above-mentioned 29 months, continuation period can also occur if, during the 18 or 29 months of continuation coverage, a second qualifying event occurs, such as a divorce, legal separation, death, Medicare entitlement or a dependent child ceasing to be a dependent. If a second event occurs during the original 18 or 29 months of continuation coverage, coverage will be extended to 36 months from the date of the original qualifying event date for eligible dependent qualified beneficiaries. It is the qualified beneficiary s responsibility to notify HRD according to the below listed notification procedures within 60 days of the second event and within the original 18 or 29 month continuation timeline. In 3 of 5

4 no event, however, will continuation coverage last beyond 36 months from the date of the event that originally made the qualified beneficiary eligible for continuation coverage. Please note that a reduction in hours followed by a termination of employment is not a secondary event. Extension of Group Health Insurance Benefits for Qualified Beneficiaries Age 62 and Over With the passing of Public Act No , effective October 1, 2003, group health insurance plans are required to give individuals who terminate employment, take a leave of absence or reduce their hours because they become eligible to receive Social Security benefits with an option to extend their continuation coverage under the group health plan. This Act requires the Plan Administrator to offer continuation coverage to all qualified beneficiaries until midnight of the day preceding the former employee s eligibility for Medicare. Social Security Disability and Secondary Qualifying Event Notification Procedures 1. Complete the enclosed Qualifying Event Notification Form. Retain a copy for your records. 2. Attach the required documentation (depending upon the qualifying event) to the notification form. 3. Mail or deliver the notification form to HRD to the address listed on the form. 4. Call HRD within 10 days to ensure the notification form has been received. Length of Continuation Coverage 36 Months If the original event causing the loss of coverage was the death of the employee, divorce, legal separation, Medicare entitlement or a dependent child ceasing to be a dependent, then each dependent qualified beneficiary will have the opportunity to continue coverage for 36 months from the date of the original qualifying event. Eligibility, Premiums and Potential Conversion Rights A qualified beneficiary does not have to show he/she is insurable to elect continuation coverage; however, he/she must have been actually covered by the plan on the day before the qualifying event to be eligible for continuation coverage. An exception to this rule is if, while on continuation coverage, a baby is born or adopted by the covered employee/qualified beneficiary. If this occurs, the newborn or adopted child can be added to the plan and will gain the rights of all other qualified beneficiaries. The COBRA timeline for the newborn or adopted child is measured from the date of the original qualifying event. Procedures and timelines for adding these individuals can be found in your plan document, available on the HRD website at and must be followed. The Plan Administrator reserves the right to verify continuation eligibility status and terminate continuation coverage retroactively if a qualified beneficiary is determined to be ineligible or if there has been a material misrepresentation of the facts. A qualified beneficiary will have to pay all of the applicable premium plus a 2% administration charge for continuation coverage. These premiums will be adjusted during the continuation period if the applicable premium amount changes. In addition, if continuation coverage is extended from 18 months to 29 months due to a Social Security disability, the University of Hartford may charge up to 150% of the applicable premium during the extended coverage period. Qualified beneficiaries will be allowed to pay on a monthly basis. In addition, there will be a maximum grace period of 30 days for the regularly scheduled monthly premiums. At the end of the 18, 29 or 36 months of continuation coverage, a qualified beneficiary may have options to enroll in an individual health plan. Contact information regarding individual health plan options will be provided at that time. Cancellation of Continuation Coverage The federal law provides that, if elected and paid for, your continuation coverage will be terminated prior to the maximum continuation period for any of the following reasons: 1. The University of Hartford ceases to provide a group health plan to any of its employees; 2. Any required premium for continuation coverage is not paid in a timely manner; 4 of 5

5 3. A qualified beneficiary becomes, after the date of the COBRA election, covered under another group health plan that does not contain any exclusion or limitation with respect to any pre-existing condition of such beneficiary other than such an exclusion or limitation which does not apply to or is satisfied by such beneficiary by reason of the Health Insurance Portability and Accountability Act; 4. A qualified beneficiary becomes, after the date of the COBRA election, entitled to Medicare; 5. A qualified beneficiary extended continuation coverage to 29 months due to a Social Security disability and a final determination has been made that the qualified beneficiary is no longer disabled; 6. A qualified beneficiary notifies HRD, in writing, that he/she wishes to cancel continuation coverage; or 7. For cause, on the same basis that the plan terminates for cause, the coverage of similarly situated non-cobra participants. If continuation coverage is terminated for any one of the above reasons, a notice will be sent to you at that time outlining any available health insurance coverage options that may be available to you. Notification of Address Change In order to protect your group health insurance continuation coverage rights and to ensure all covered individuals receive information properly and efficiently, you are required to notify HRD of any address change as soon as possible by completing an Address Notification Form. Failure on your part to do so may result in delayed notifications or a loss of continuation coverage options. Conclusion Please remember that this notice is simply a summary of your potential future continuation coverage options and not a description of your actual health benefits under the plan. If an actual qualifying event occurs and it is determined that you are eligible for continuation coverage, you will be notified of your rights at that time. If you have any questions regarding any information contained in this notice, you may contact HRD, or you may contact the nearest regional or district office of the U.S. Department of Labor s Employee Benefits Security Administration (EBSA). Contact information for the regional and district EBSA offices can be located at Thank you. Sincerely, Senior Human Resources Specialist Human Resources Development Enclosures 5 of 5

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