City Of New York Employee Benefits Program Continuation Of Coverage Application (Page 7 of 8) in pdf

The termination of your spouse/domestic partner's employment (for reasons other than gross

misconduct) or reduction in your spouse/domestic partner's hours of employment;

Divorce or legal separation from your spouse.

In the case of an eligible dependent child of an employee or retiree (including a newborn child who

was born to the covered beneficiary or an adopted child who is placed for adoption with the covered

beneficiary during a period of COBRA continuation coverage) he or she has the right to continue coverage

under any of the available NYC health benefits plans and the applicable welfare fund if coverage is reduced

or terminated for any of the following reasons:

The death of the covered parent;

The termination of the covered parent’s employment (for reasons other than gross

misconduct) or reduction in the parent’s hours of employment;

The dependent ceases to be a “dependent child” under the terms of the Employee

Benefits Program;

Retirement of the covered parent (see “Retiree” above).

If you are a Medicare-eligible spouse/domestic partner or dependent, see section on Medicare-eligible's.

Disabled Persons

If a disability has led to Medicare eligibility, see section on Medicare-eligibles below.

Covered persons who are disabled, under the definition established by the Social Security law, up to

60 days after the COBRA qualifying event of termination of employment or reduction of hours, are entitled to

continue coverage for up to a total of twenty-nine (29) months from the date of the initial qualifying event.

The cost of coverage during the last eleven (11) months of this extended period is one hundred and fifty

percent (150%) of the City cost for the benefit. Persons so disabled must inform the health plan within sixty

(60) days of the disability determination and within thirty (30) days of disability ceasing.

Medicare-Eligibles

Employees, retirees, spouses/domestic partners and dependents who are eligible for Medicare may

be eligible to receive continued coverage, similar to COBRA, under the City’s Medicare-Supplemental plans.

Periods of eligibility shall date from the original qualifying event up to eighteen (18) months in the case of

loss of coverage because of termination of employment or reduction in hours, or up to thirty-six (36) months

in the case of loss of coverage for all other reasons.

If a COBRA qualifying event occurs and you lose coverage, but you and/or your dependents are

Medicare-eligible, you may continue coverage by using the COBRA Continuation of Coverage application

form. You should indicate your Medicare claim number and effective dates where indicated on the form for

Medicare-eligible family members. If you and/or your dependents are about to become

eligible

for

Medicare, and are already continuing coverage under COBRA, inform the carrier of Medicare eligibility for

you and/or your dependents, at least thirty (30) days prior to date of Medicare eligibility.

COBRA-

enrolled dependents of the person who becomes Medicare eligible will be able to continue their COBRA

coverage, whether or not the Medicare-eligible person enrolls in the Medicare-Supplemental coverage. The

COBRA continuation period for dependents will be unaffected by the decision of the Medicare-eligible

employee or retiree.

NOTE: You should contact your carrier for information about other Medicare-Supplemental plans which are

offered; some other plans may be better suited to your needs and/or less costly than the plan which is

provided under the City’s contract.

City Of New York Employee Benefits Program Continuation Of Coverage Application Page 7

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