Bcbs General Notice Of Cobra Continuation Coverage Rights Instruction (Page 3 of 4) in pdf

Duration of COBRA Coverage for

There are two ways in which the 18-month period of COBRA

Covered Employees

continuation coverage can be extended.

If you are the covered employee and the qualifying event is

Disability Extension of 18-Month Period of

the end of employment or reduction in hours of employment,

Continuation Coverage

COBRA continuation coverage will continue for up to a total of

If you or anyone in your family covered under the plan is

18 months from the date of your termination of employment or

determined by the Social Security Administration (SSA)

reduction in hours, assuming you pay your COBRA premiums on

to be disabled and you timely notify the Plan Administrator

time. If, apart from COBRA, your employer continues to

or its designee in writing, you and your entire family may be

provide coverage to you after your termination of employment

entitled to receive up to an additional 11 months of COBRA

or reduction in hours (regardless of whether such extended

continuation coverage, for a total maximum of 29 months.

coverage is permitted under the terms of the plan), the

The disability would have to have started at some time before

extended coverage you receive will ordinarily reduce the time

the 60th day of COBRA continuation coverage and must last

period over which you may buy COBRA benefits.

at least until the end of the 18-month period of continuation

coverage. In order for this disability extension to apply, you

If you are the covered employee and you are on a leave of

must timely notify the Plan Administrator or its designee in

absence covered by the Family and Medical Leave Act of

writing (using the SSA Disability Notice procedures specified

1993 (FMLA), and you do not return to work, you will be given

below) of the SSA disability determination before the end of

the opportunity to buy COBRA coverage. The period of your

the 18-month period of continuation coverage and within

COBRA coverage will begin when you fail to return to work

60 days after the later of (i) the date of the initial qualifying

following the expiration of your FMLA leave or you inform your

event, (ii) the date on which coverage would be lost

employer that you do not intend to return to work, whichever

because of the initial qualifying event, or (iii) the date of the

occurs first.

SSA disability determination.

Duration of COBRA Coverage for Covered

Spouses and Dependent Children

SSA Disability Notice Procedures: Any SSA disability

notices that you provide must be in writing. Oral notice,

If you are a covered spouse or dependent child and the

including notice by telephone, is not acceptable. You must

qualifying event is the end of employment or reduction of the

mail, fax or hand deliver your notice to:

employee’s hours, COBRA continuation coverage generally

lasts for up to a total of 18 months from the date of termination

Blue Cross and Blue Shield of Alabama

of employment or reduction in hours, provided that COBRA

Attention: Customer Accounts

premiums are paid on time. However, if the covered employee

450 Riverchase Parkway East

became enrolled in any part of Medicare before the end of his

Birmingham, AL 35244-2858

or her employment or reduction in hours, COBRA continuation

Fax: 205-220-6884 or 1-888-810-6884 (toll free)

for the covered spouse and dependent children will continue

for up to 36 months from the date of Medicare enrollment or

Your notice must be received by Blue Cross and

18 months from the date of termination of employment or

Blue Shield of Alabama no later than the last day of the

reduction in hours, whichever period ends last. For example,

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

if a covered employee becomes enrolled in any part of

your notice must be postmarked no later than the last

Medicare 8 months before the date on which his employment

day of the required 60-day notice period. The notice

terminates, COBRA continuation coverage for his spouse and

you provide must state:

children can last up to 36 months after the date of Medicare

enrollment, which is equal to 28 months after the date of the

•

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

qualifying event that is termination of employment (36 months

are losing coverage,

minus 8 months).

•

the name and address of the employee covered

under the plan,

If you are a covered spouse or dependent child and the

•

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

qualifying event is the death of the employee, the employee’s

beneficiary(ies),

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

•

the qualifying event and the date of the qualifying event,

your divorce, or a dependent child’s losing eligibility as a

•

the name of the disabled qualified beneficiary,

dependent child, COBRA continuation coverage lasts for up

•

the date that the qualified beneficiary became

to a total of 36 months, provided that COBRA premiums are

disabled, and

paid on time.

•

the date that the SSA made its determination of disability.

MKT-116 (Rev. 7-2014)

Bcbs General Notice Of Cobra Continuation Coverage Rights Instruction Page 3

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