Retiree Health & Welfare
Health & Welfare Plan
COBRA Continuation Coverage
COBRA (the Consolidated Omnibus Budget Reconciliation Act of 1985) provides individuals the right to continue their health coverage by paying a monthly premium if they lose coverage under the Plan because of a “qualifying event.” If COBRA is elected and premiums are paid in a timely manner, health coverage starts from the date coverage ends because of a qualifying event.
The length of COBRA coverage is as follows:
Loss of eligibility due to:
|Length of COBRA Coverage|
|Participant||Termination of employment for reasons other than gross misconduct||
|Reduction in hours||
|Spouse||Termination of employee’s employment for reasons other than gross misconduct||
|Death of employee||
|Dependent||Termination of employee’s employment for reasons other than misconduct||
|Death of employee||
|Divorce of parents||
|Attainment of age 26||
|Parent’s eligibility for Medicare||
Under COBRA, only “qualified beneficiaries” are entitled to continued coverage. A qualified beneficiary is any individual who was covered under the Plan on the day before the qualifying event.
While a Participant’s COBRA coverage is in effect, the Participant may add a new spouse, a newborn child, an adopted child or a child placed with the Participant for adoption (for whom the Participant has financial responsibility). However, a new spouse, even though eligible as a dependent, does not become a qualified beneficiary and, therefore, does not have individual COBRA continuation rights. Adding a spouse or child to the coverage may increase the amount of your COBRA premium.
COBRA coverage is not available if the Participant or Dependent is covered by any other group insurance. COBRA coverage is also not available if the person has Medicare.
COBRA coverage is only available to a Retired Employee if he returns to work and regains Active Eligibility in the Plan or he does not otherwise qualify for Retiree coverage at retirement.
If your qualifying event entitles you to 18 months of COBRA coverage and you or a covered Dependent was disabled at the time of the qualifying event (or becomes disabled during the first 60 days of continuation coverage), you and any other covered Dependent may be eligible to continue your COBRA coverage at increased premium rates for up to an additional 11 months, for a total of up to 29 months.
To qualify for the additional months of coverage, the Social Security Administration must make a formal written determination that you or your Dependent is disabled and, therefore, is entitled to Social Security Disability income benefits before the 18-month period expires. You or your Dependent must notify the Fund Office of the Social Security determination within 60 days of the date you receive the determination and before the 18-month period expires. If the disability does not continue throughout the continuation period, you must notify the Fund Office of any later determination that you or your Dependent is no longer disabled.
Length of Coverage if you are enrolled in Medicare
If you are an Active Participant entitled to Medicare and you experience one of the qualifying events that entitles you to 18 months of COBRA coverage (reduction in your work hours, voluntary resignation or termination of employment), your eligible Dependents would be entitled to COBRA for a period of 18 months (29 months if the disability extension applies) from the date of the reduction in your work hours or resignation/termination of your employment or 36 months from the date you became entitled to Medicare, whichever is longer.
Second Qualifying Events
If your Dependents are in an 18-month COBRA coverage period because of a reduction in your work hours, your voluntary resignation or a termination of your employment and one of the following qualifying events occurs, the maximum COBRA period for your dependents will increase to 36 months:
- You get a divorce
- You become entitled to Medicare
- Your death
- Your child ceases to meet the Plan’s definition of an eligible dependent (in this case, only the child may be entitled to an additional 18 months of coverage)
This extension is only available to individuals who were covered Dependents at the time of the initial qualifying event and to children who are born to, or adopted by the Participant, during the initial 18-month period of coverage. The extension is not available to anyone who became the Participant’s spouse following a qualifying event (e.g., the termination of employment or reduction in hours).
The maximum period of coverage under COBRA is 36 months regardless of how many qualifying events occur.
Active Participants are not entitled to COBRA coverage for more than 18 months (29 months in cases of disability). Even if you experience a reduction in your work hours followed by a resignation or termination of employment, the resignation or termination of employment is not treated as a second qualifying event and you may not extend your coverage.
Qualifying Event Notification Requirements
In order to be eligible for COBRA coverage, the Fund Office must be notified, in writing within 60 days of the qualifying event.
If the qualifying event is a divorce or a child losing dependent status, you or the dependent must notify the Fund Office within 60 days of the date of the qualifying event.
If the Fund Office is not notified, in writing, within this time frame, the individual losing eligibility as a dependent will forfeit his or her right to enroll in the COBRA continuation plan.
Electing COBRA Continuation Coverage
When the Fund Office receives notice of a qualifying event, it will send the qualifying beneficiary information about coverage options and COBRA election forms. Information sent to the Participant or Spouse will be deemed to have been sent to dependent children.
You and/or your covered Dependents must make your election within 60 days of the later of:
- The date of the qualifying event;
- The date you would have lost coverage because of a qualifying event; or
- The date you and/or your Dependents are sent the election form and COBRA information.
If you and/or any of your covered Dependents do not elect COBRA coverage within the 60-day period, your/their health coverage will end and the Plan will not pay claims for services incurred on and after the date coverage terminates.
If during your COBRA coverage period, you acquire a new Dependent due to marriage, birth, adoption or placement for adoption of a child, you may enroll that Spouse or Dependent Child for coverage for the remainder of your COBRA period provided you notify the Fund Office and enroll the new Dependent within 30 days of the marriage, birth, adoption or placement for adoption. Adding a new Dependent may cause an increase in the amount of the monthly COBRA premium.
If you elect COBRA continuation coverage, you will be entitled to the same health coverage that is provided to other Participants and their family members in the Plan whose situation is similar to yours.
There are two different options and premiums under COBRA. One option provides only medical and hospital benefits (COBRA Core Plan). The other option provides medical, hospital, prescription drug, dental and vision benefits (COBRA Full Plan). There is no coverage for life insurance under the COBRA Plans.
COBRA coverage is an extension of your benefits prior to loss of eligibility. Therefore, if you had already satisfied the applicable calendar year deductible and out-of-pocket maximums, new ones will not be taken.
If the coverage provided by the Plan to Active Participants is changed in any respect, those changes will apply at the same time and in the same manner for everyone covered under the COBRA Plan.
Paying for COBRA Continuation Coverage
You are responsible for the entire cost of COBRA coverage. The Fund Office will notify you of the COBRA premium amounts, which can change on a yearly basis.
Payment rules are:
- Payments can be mailed to the Fund Office if made by check, cashier’s check or money order.
- If you elect COBRA coverage, you must, within 45 days of your election date, submit your first payment to the Fund Office. This first payment must include payment for all calendar months from the expiration of coverage through the calendar month that ends prior to the date of the first payment.
- After the initial payment is made, payments must be made monthly to continue coverage. Failure to make a monthly payment within 30 days of the beginning of the coverage month will result in termination of coverage as of the end of the period for which the last payment has been made.
It is the responsibility of the qualified beneficiary to submit payments when due.
Termination of COBRA Continuation Coverage
COBRA continuation coverage will terminate on the earliest of:
- The first of the month for which you or your Dependents do not pay the premium by the due date; or
- The first of the month that begins 30 days after Social Security determines that the qualified beneficiary is no longer disabled if the coverage is under the 11-month extension for disabled individuals; or
- The first of the month following the expiration of the maximum COBRA coverage period for which the individual qualifies; or
- The date on which the Trustees reduce the amount of COBRA coverage available or no longer provide health coverage; or
- The date on which the plan you have chosen is terminated, in which case, you may have the opportunity to change to another plan offered by the Fund; or
- The date on which the person receiving coverage becomes covered by another group health plan (as an employee, spouse or dependent) that does not contain any exclusion or limitation for a pre-existing condition; or
- The date on which the person receiving coverage becomes entitled to Medicare benefits after the date of election of COBRA; or
- The date on which your employer withdraws from this Plan and establishes or joins another group health plan covering a significant number of its employees formerly covered by this Plan.
Conversion to Individual Coverage (Applicable only to HMO Participants)
Participants and eligible family members whose coverage through an HMO ends after exhaustion of COBRA and Cal-COBRA are allowed to purchase individual conversion coverage through their HMO without evidence of insurability. Individuals must apply for conversion coverage and pay the premium to the HMO within 31 days of the loss of their coverage.
To take advantage of this provision, you must remain in the HMO plan.