Bcbs General Notice Of Cobra Continuation Coverage Rights Instruction Page 4
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4Other coverage options besides COBRA
Your notice must also include a copy of the SSA disability
Continuation Coverage
determination. For your convenience, we have prepared a
form of Notice by Qualified Beneficiaries that you may use
Instead of enrolling in COBRA continuation coverage, there
to notify Blue Cross and Blue Shield of Alabama of a SSA
may be other coverage options for you and your family
disability determination. You may get a copy of this form,
through the Health Insurance Marketplace, Medicaid, or other
at no cost to you, from either the Plan Administrator or
group health plan coverage options (such as a spouse’s plan)
Blue Cross and Blue Shield of Alabama. If these procedures
through what is called a “special enrollment period.” Some
are not followed or if the notice is not provided in writing to
of these options may cost less than COBRA continuation
Blue Cross and Blue Shield of Alabama within the required
coverage. You can learn more about many of these options
time period, there will be no disability extension of COBRA
at
continuation coverage. You must also notify Blue Cross
and Blue Shield of Alabama within 30 days of any revocation
If You Have Questions
of Social Security disability benefits.
Questions concerning your plan or your COBRA continuation
coverage rights should be addressed to the Plan Administrator.
Second Qualifying Event Extension of 18-Month
For more information about your rights under ERISA,
Period of Continuation Coverage
including COBRA, the Health Insurance Portability and
If your family experiences another qualifying event while
Accountability Act (HIPAA), and other laws affecting group
receiving 18 months of COBRA continuation coverage, the
health plans, contact the nearest Regional or District
spouse and dependent children in your family can get up
Office of the U.S. Department of Labor’s Employee Benefits
to 18 additional months of COBRA continuation coverage,
Security Administration (EBSA) in your area or visit the EBSA
for a maximum of 36 months, if timely notice of the second
web site at (addresses and phone
qualifying event is properly given to the plan. This extension
numbers of Regional and District EBSA Offices are available
may be available to the spouse and any dependent children
through EBSA’s web site.). For more information about the
receiving continuation coverage if the employee or former
Marketplace, visit
employee dies, becomes enrolled in Medicare (under Part A,
Keep Your Plan Informed of Address Changes
Part B, or both), or gets divorced, or if the dependent child
stops being eligible under the plan as a dependent child, but
In order to protect your family’s rights, you should keep the
only if the event would have caused the spouse or dependent
Plan Administrator informed of any changes in the addresses
child to lose coverage under the plan had the first qualifying
of family members. You should also keep a copy, for your
event not occurred.
records, of any notices you send to the Plan Administrator
Plan Administrator Contact Information
For example, the former employee becoming enrolled in
Medicare will rarely be a second qualifying event that would
Group Health Plan(s) Covered by This Notice:
entitle the spouse or dependent children to extended COBRA
coverage. This is so because, for plans that are subject to
Plan Administrator: ___________________________________
COBRA and the Medicare Secondary Payer (MSP) laws, this
Name/Position: ______________________________________
event would not cause the spouse or dependent children to
lose coverage under the plan had the first qualifying event
Address: ____________________________________________
not occurred.
Phone Number: ______________________________________
In order for this 18-month extension to apply, you must timely
notify the Plan Administrator in writing (using the notice
procedures specified in the above paragraph on which coverage
would be lost because of the event, whichever is later. In
addition, your notice must also name the second qualifying
event and the date of the second qualifying event. For your
convenience, we have prepared a form of Notice by Qualified
Beneficiaries of Second Qualifying Event that you may use
to notify the Plan Administrator of a second qualifying event.
You may get a copy of this form, at no cost to you, from the
Plan Administrator. If these procedures are not followed or if
the notice is not provided in writing to the Plan Administrator
during the required 60-day notice period, there will be no
extension of COBRA coverage as a result of the second
qualifying event.
MKT-116 (Rev. 7-2014)
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