Bcbs General Notice Of Cobra Continuation Coverage Rights Instruction (Page 2 of 4) in pdf

•

The parent-employee’s employment ends for any reason

Administrator during the 60-day notice period, any spouse or

other than his or her gross misconduct;

dependent child who loses coverage under the plan will not

•

The parent-employee becomes enrolled in Medicare

be offered the option to elect COBRA coverage as a result of

(under Part A, Part B, or both);

these qualifying events.

•

The parents become divorced; or

•

The child is no longer eligible for coverage under the plan

Qualifying Event Notice Procedures: Any notice of a

as a “dependent child.”

qualifying event that you provide must be in writing. Oral

notice, including notice by telephone, is not acceptable.

A child of the covered employee or former employee who

You must mail or hand deliver your notice to the Plan

is receiving benefits under the plan pursuant to a qualified

Administrator identified at the end of this notice. Your notice

medical child support order is entitled to the same rights under

must be received by the Plan Administrator, identified at the

COBRA as a dependent child of the covered employee. A child

end of this notice, no later than the last day of the required

born to, adopted by or placed for adoption with a former

60-day notice period unless you mail it. If mailed, your notice

employee during the period of COBRA coverage may also

must be postmarked no later than the last day of the required

be a qualified beneficiary if the former employee is a qualified

60-day period. The notice you provide must state:

beneficiary who has elected COBRA coverage.

•

the name of the plan or plans under which you lost or are

losing coverage,

Additional Qualifying Event for

•

the name and address of the employee covered under

Covered Retirees

the plan,

If the plan provides retiree health coverage, sometimes

•

the name(s) and address(es) of the qualified

filing a proceeding in bankruptcy under Title 11 of the United

beneficiary(ies), and

States Code can be a qualifying event. If a proceeding in

•

the qualifying event and the date of the qualifying event.

bankruptcy is filed with respect to the employer sponsoring

the plan, and that bankruptcy results in the loss of coverage

If the qualifying event is a divorce, your notice must include

of any retired employee covered under the plan, the retired

a copy of the divorce decree. For your convenience, we

employee will become a qualified beneficiary with respect

have provided a form of Notice by Qualified Beneficiaries of

to the bankruptcy. The retired employee’s spouse, surviving

Initial Qualifying Event that you may use to notify the Plan

spouse, and dependent children will also become qualified

Administrator of a qualifying event. You may also get a copy of

beneficiaries if bankruptcy results in the loss of their

this form, at no cost to you, from the Plan Administrator.

coverage under the plan.

Other Notices You Must Give: You must also give notice of

When is COBRA Coverage Available?

other events that are described later in this notice.

The plan will offer COBRA continuation coverage to qualified

For example, please refer to the later paragraphs in this

beneficiaries only after the Plan Administrator has been

notice entitled “Disability extension of 18-Month Period of

notified that a qualifying event has occurred. When the

Continuation Coverage” and “Second Qualifying

qualifying event is the end of employment or reduction of

Event Extension of 18-Month Period of Continuation

Coverage” for the notice procedures and notice time periods

hours of employment, death of the employee, commencement

of a proceeding in bankruptcy with respect to the employer if

that apply to you in those circumstances.

the plan provides retiree health coverage, or the employee’s

How is COBRA Coverage Provided?

becoming enrolled in Medicare (under Part A, Part B, or both),

the employer must notify the Plan Administrator of

Once the Plan Administrator receives timely notice that a

the qualifying event. You Must Give Notice of Some

qualifying event has occurred, COBRA continuation coverage

Qualifying Events

will be offered to each of the qualified beneficiaries. Each

qualified beneficiary will have an independent right to elect

For the other qualifying events (divorce of the employee and

COBRA continuation coverage. Covered employees may elect

spouse or a dependent child’s losing eligibility for coverage

COBRA continuation coverage on behalf of their spouses, and

as a dependent child), you must timely notify the Plan

parents may elect COBRA continuation coverage on behalf of

Administrator in writing (using the procedures specified in the

their children. COBRA continuation coverage is a temporary

paragraph below entitled “Qualifying Event Notice Procedures”)

continuation of coverage.

within 60 days after the qualifying event occurs or within 60

days after the date on which coverage would be lost because

of the event, whichever is later. If these procedures are not

followed or if the notice is not provided in writing to the Plan

MKT-116 (Rev. 7-2014)

Bcbs General Notice Of Cobra Continuation Coverage Rights Instruction Page 2

Related Articles

Related forms

Related Categories