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MODEL GENERAL NOTICE
OF COBRA CONTINUATION COVERAGE RIGHTS
(For use by single-employer group health plans)
** 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.
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 [choose and enter appropriate information: must
pay or are not required to 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.
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, add the following paragraph:]
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 [enter name of employer sponsoring the plan], 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 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, [add if Plan
provides retiree health coverage: commencement of a proceeding in
bankruptcy with respect to the employer,] or the employee's becoming
entitled to Medicare benefits (under Part A, Part B, or both), the
employer must notify the Plan Administrator of the qualifying event.
You Must Give Notice of Some Qualifying Events
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 Plan Administrator within 60
days [or enter longer period permitted under the terms of the Plan] after
the qualifying event occurs. You must provide this notice to: [Enter name
of appropriate party]. [Add description of any additional Plan procedures
for this notice, including a description of any required information or
documentation.]
How is COBRA Coverage Provided?
Once the 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.
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 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 60th day of COBRA continuation
coverage and must last at least until the end of the 18-month period of
continuation coverage. [Add description of any additional Plan procedures
for this notice, including a description of any required information or
documentation, the name of the appropriate party to whom notice must be
sent, and the time period for giving notice.]
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
www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District
EBSA Offices are available through EBSA’s website.)
Keep Your Plan Informed of Address Changes
In order to protect your family’s rights, you should keep the 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
[Enter name of group health plan and name (or position), address and phone
number of party or parties from whom information about the plan and COBRA
continuation coverage can be obtained on request.]
One Stamford Landing, Suite 101,
Stamford, CT 06902
Phone: 203-356-1100
Cell: 203-979-4173
Fax: 203-967-8733
randy@rjallc.com
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