Cobra Election Form - Mba/biaw/nmta/camps Health Insurance Trust (Page 2 of 2) in pdf

MBA/BIAW/NMTA/CAMPS HEALTH TRUST

Continuation Coverage (COBRA)

Terms and Conditions for Participation

1. You are eligible for COBRA Continuation Coverage only if (1) the Employer is a current participant in the MBA/BIAW/NMTA/CAMPS Health Insurance

Trust program and (2) the Employer has certifi ed it is subject to the Continuation Coverage law.

2. To elect Continuation Coverage, you must complete and submit this Continuation Coverage Election Form to the Trust Administrator within

60 days after the day coverage terminated, or, if later the day your Employer gave you this Continuation Coverage Election Form (provided

the Employer met their 44 day COBRA notifi cation requirement). If the Employer does not meet the 44 day notifi cation requirement

described above, this Election Form must be received, or postmarked, within 104 days from the later of the COBRA qualifying event or the

date coverage under the plan terminates. If your Election Form is not received within the 104 day period Continuation Coverage will not be

provided through the MBA/BIAW/NMTA/CAMPS Trust program.

3. You must submit your fi rst Continuation Coverage rate payment within 45 days after the date you elect Continuation Coverage on the

Election Form. Your fi rst retroactive rate payment must be for the full amount necessary to cover the initial rate months. The ”initial rate

months” are the months that end on or before the 45th day after the date of the Continuation Coverage election. After the fi rst rate

payment, rate payments are due on the fi rst day of each month for that month’s Continuation Coverage, and must be paid in full within 30

days after the fi rst day of the month. If you fail to make full payment within the required time periods, Continuation Coverage terminates

retroactively to the last day of the month for which full timely payment has been made, and will NOT be reinstated.

4. The rate for Continuation Coverage is 102% of the rate charged to similarly situated individuals covered under the Former Employer’s

group plan. Rates are subject to change at least annually. Rates are also subject to change in the event of a benefi t change elected by the

Former Employer. COBRA participants are eligible only for the same MBA/BIAW/NMTA/CAMPS Medical, Dental and Vision benefi ts selected by

the Former Employer.

5. If the employee’s spouse, domestic partner or dependent child loses plan coverage because of the employee’s death, divorce, or termination of

Domestic Partnership, the dependent child loses plan coverage because he or she ceases to be a dependent under the plan, the maximum cover

age period (for spouse, domestic partner and dependent child) is 3 years from the fi rst day of the month following the qualifying event. If the employee,

spouse, domestic partner or dependent child involuntarily loses plan coverage because of a termination, reduction in hours of the employee’s

employment or employee becomes entitiled to Medicare, the maximum continuation coverage period (for the employee, spouse or dependent child) is

18 months from the fi rst day of the month following the termination or reduction in hours of employment. There are two exceptions:

•

If an employee or family member is disabled at any time during the fi rst 60 days after the termination or reduction in hours of

employment, the maximum coverage period for the disabled individual and the family members who elect Continuation Coverage is

29 months from the fi rst day of the month following termination or reduction in hours. The disability that extends the 18 month

coverage period must be determined under Title II (Old Age, Survivors, and Disability Insurance) or Title XVI (Supplemental Security

Income) of the Social Security Act. For the 29-month continuation coverage period to apply, notice of the determination of disability

under the Social Security Act must be provided by the disabled individual to the MBA/BIAW/NMTA/CAMPS Trust Administrator within the 18-month

coverage period and within 60 days after the date of the determination.

•

If a second qualifying event that gives rise to a 36 month maximum coverage period occurs (for example, the employee dies,

divorces, termination of domestic partnership or a child ceases to be an eligible dependent) within the 18-month or 29-month coverage

period, the maximum coverage period for the spouse, domestic partner and dependent child becomes 3 years from the fi rst day of the month following

termination or reduction in hours of employment.

6. Continuation Coverage automatically terminates (even before the end of the maximum coverage period) when any one of the following 6

events occur:

•

The Former Employer no longer provides a medical, dental or vision plan through the MBA/BIAW/NMTA/CAMPS Health Insurance Trust (as the

case may be) to any of its employees;

•

The full rate payment for Continuation Coverage is not timely paid.

•

You (employee, spouse, domestic partner or dependent child) become covered under another group health plan .

•

You (employee, spouse, domestic partner or dependent child) become entitled to Medicare benefi ts (applies only to person entitled to

Medicare).

•

If you became entitled to a 29-month maximum coverage period, but then there is a fi nal determination under Title II or Title XVI

of the Social Security Act that the disabled qualifi ed benefi ciary is no longer disabled. However, Continuation Coverage will not end

until the month that begins more than 30 days after the determination.

• An event occurs that permits termination of coverage under the MBA/BIAW/NMTA/CAMPS Trust for cause.

7. Your application cannot be processed until we receive your initial premium payment. In addition, all claims

including prescription drug benefi ts, occurring after your loss of coverage will be held in pending status. Once

full payment has been received, and your former employer has paid their monthly premium, all eligible claims

will be released for payment according to the terms of the health insurance contract.

MBA/BIAW/NMTA/CAMPS Health Trust—c/o EPK & Associates, Inc.—15375 SE 30th Pl. #380 Bellevue, WA 98007—Phone 1-800-545-7011

11/16

Cobra Election Form - Mba/biaw/nmta/camps Health Insurance Trust Page 2

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