LLEEGGAALL NNOOTTI ICCEESS
COBRA
Model General Notice of COBRA Continuation Coverage Rights (For use by single-employer group health plans) **ContinuationCoverageRightsUnder COBRA**
Introduction You’re getting thisnotice because you recentlygained coverage under a group health plan (the Plan). This notice has important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice explains COBRA continuationcoverage, when it may become available to you and your family, and what you need to do to protectyour right to get it. When you become eligible for COBRA, you may also become eligible for other coverage options that may cost less than COBRA continuation coverage. 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 and other members of your family when group health coverage would otherwise end. For more 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. You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible(such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees. What is COBRA continuation coverage? COBRAcontinuation coverage is a continuation of Plan coverage when it would otherwise end because of a lifeevent. This is also called 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. If you’re an employee, you’ll become a qualifiedbeneficiary if you loseyour coverage under the Plan because of the following qualifying events: • Your hours of employment are reduced, or • Your employment ends for any reason other than your grossmisconduct. If you’re the spouse of an employee, you’ll become a qualified beneficiaryif you loseyour coverage under the Plan because of the following qualifying events: • Yourspouse 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 of the following qualifying events • 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 childstopsbeing eligiblefor coverage under the Plan as a “dependent child.” When is COBRA continuation coverage available? The Plan will offer COBRA continuation coverage to qualifiedbeneficiariesonly after the Plan Administratorhas been notified that a qualifying event has occurred. The employer must notify the Plan Administratorof the following qualifying events: • The end of employment or reduction of hours of employment; • Death of the employee; • The employee’s becomingentitledto Medicarebenefits (under Part A, Part B, orboth). For all 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 after the qualifying event occurs. You must providethis notice to the appropriate party.
BENEFITS GUIDE
LEGAL NOTICES - COBRA I
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