Model Cobra Continuation Coverage Election Notice (Page 4 of 8) in pdf

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 [add if applicable: 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 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 (note: there are limitations on plans’

imposing a preexisting condition exclusion and such exclusions will become prohibited

beginning in 2014 under the Affordable Care Act),

 a qualified beneficiary 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.

Model Cobra Continuation Coverage Election Notice Page 4