Continuation Coverage Rights Under Cobra

What is COBRA Continuation Coverage?

COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a “qualifying event.”  Specific qualifying events are listed later in this notice.  After a qualifying event, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.”  You, your spouse, and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event.  Only those dependents who are covered by the Plan on the date of the qualifying event can be considered qualified beneficiaries for purposes of COBRA continuation coverage. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens:

• Your hours of employment are reduced (including if you fail to work sufficient hours in a designated work period necessary to maintain plan eligibility), or
• Your employment ends for any reason other than your gross misconduct (including retirement).

 

If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens:

• Your spouse dies;
• Your spouse’s hours of employment are reduced;
• Your spouse’s employment ends for any reason other than his or her gross misconduct;
• Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or
• You become divorced from your spouse.

 

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happens:

• The parent-employee dies;
• The parent-employee’s hours of employment are reduced;
• The parent-employee’s employment ends for any reason other than his or her gross misconduct (including retirement);
• The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);
• The parents become divorced; or
• The child stops being eligible for coverage under the plan as a “dependent child.”

You Must Give Notice of Some Qualifying Events

You Must Give Notice of Some Qualifying Events

For the other qualifying events (divorce of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the Fund Office within 60 days of the later of the qualifying event or the date coverage is lost due to the qualifying event.

The Fund Office tracks dependent children’s ages and student status and will usually inform you (and provide a COBRA Election Notice and Form) when your dependent child ages out of the Fund or is no longer eligible for coverage because he or she is no longer a full-time student. However, you (or your dependent child) are ultimately responsible for notifying the Fund Office of the qualifying event according to the procedure described below if your dependent child wishes to elect COBRA continuation coverage.

In order to provide the Fund with notice of any of the above situations, you must send a letter to the Fund Office containing the following information: your name, for which of the events you are providing notice, the date of the event, the date on which the dependent spouse and/or child(ren) will lose coverage.  In the case of divorce, you must provide a copy of the divorce decree, including the signature page. Notice should be sent to the Fund Office at:

 

Philadelphia Federation of Teachers Health & Welfare Fund

1816 Chestnut Street

Philadelphia, PA 19103

Length of COBRA Continuation Coverage

For the Employee and/or Dependents – 18 Months of COBRA Continuation Coverage

COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months for the employee and/or dependents (who are qualified beneficiaries).  There are two ways in which this 18-month period of COBRA continuation coverage can be extended as described below.

 

For Dependents – Qualified Beneficiaries Other than the Employee – 36 Months of COBRA Continuation Coverage

When the qualifying event is the death of the employee, the employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce, or a dependent child’s losing eligibility as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months for spouses and dependents who are qualified beneficiaries.

When the qualifying event is the end of employment or reduction of the employee’s hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement.  For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months).

 

 

Situations where the length of COBRA continuation coverage can be extended past 18-months

 

(1) Disability extension of 18-month period of continuation coverage

If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Fund Office in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months.  To be entitled to this extension, the disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage.

You must provide the Fund Office with written notice no later than 60 days after the later of (1) the date of the disability determination by the Social Security Administration or (2) the date of the qualifying event and before the end of the 18-month COBRA period. You must also provide a copy of the Social Security Administration Disability Determination along with your notice.

If the qualified beneficiary is determined by the SSA to no longer be disabled, you must notify the Plan of that fact within 30 days after the SSA’s determination

 

(2) Second qualifying event extension of 18-month period of continuation coverage for dependents

If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family who are qualified beneficiaries can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given (as described below) to the Plan.  This extension may be available to the spouse and any dependent children (if they are qualified beneficiaries) receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

You must notify the Plan in writing within 60 days of the date of the relevant second qualifying event.  You must send a letter to the Fund Office containing the following information: your name, for which of events you are providing notice, and the date of the event along with a copy of the supporting documentation (a copy of the divorce decree, a copy of a child’s birth certificate or other proof of age, a copy of the employee’s death certificate or a copy of the employee’s Medicare card).

 

 

Special Enrolment Rights

 

Addition of New Dependents

If, while you are enrolled for COBRA Continuation Coverage, you marry, have a newborn child, or have a child placed with you for adoption, you may enroll that spouse or child for coverage for the balance of the period of your COBRA Continuation Coverage.  You must notify the Fund Office in writing [within 30 days] of the marriage, birth or placement in order to add the new dependent to your coverage.  Adding a child or spouse may cause an increase in the amount you must pay for COBRA Continuation Coverage.

Any Qualified Beneficiary can add a new spouse or child to his or her COBRA Continuation Coverage.  However, the only newly added family members who have the rights of a Qualified Beneficiary, such as the right to stay on COBRA Continuation Coverage longer in certain circumstances, are children born to, adopted, or placed for adoption with the Covered Employee.  Adding a new dependent may cause an increase in the amount you must pay for COBRA Continuation Coverage.

 

Loss of Other Group Health Plan Coverage

If, while you are enrolled for COBRA Continuation Coverage, your spouse or dependent loses coverage under another group health plan, you may enroll the spouse or dependent for coverage for the balance of the period of COBRA Continuation Coverage provided you notify the Fund Office within [30] days of the loss of other coverage.  The spouse or dependent must have been eligible for but did not elect COBRA continuation coverage under the terms of this Plan and, when the COBRA Election was previously offered under this Plan and declined, the spouse or dependent must have been covered under another group health plan or had other health insurance coverage.

The loss of coverage must be due to exhaustion of COBRA Continuation Coverage under another plan, termination as a result of loss of eligibility for the coverage, or termination as a result of employer contributions toward the other coverage being terminated.  Loss of eligibility does not include a loss due to failure of the individual or participant to pay premiums on a timely basis or termination of coverage for cause.

Keep Your Plan Informed of Address Changes

In order to protect your family’s rights, you should keep the Fund Office informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Fund Office.