COBRA (Self Payment) Rules

COBRA Eligibility

If you cease to be an active participant for any reason other than gross misconduct, you have the right to continue your Health Benefits for a period of up to 36 months, starting from the date your employer terminates Welfare Contributions on your behalf. Immediate notification of termination must be given the Fund Office in order to maintain your health insurance benefits through direct payments.

• Your spouse (husband or wife) may also continue his or her Health Benefits on a direct payment basis under any of the following circumstances:
• upon your death (providing you were eligible at the time of death).
• upon divorce or legal separation from you.
• upon your termination of employment for retirement or any reason other than gross misconduct.

Your dependent children (as defined in the plan) may also continue their health benefits on a direct payment basis under any of the following circumstances:

• upon your death (providing you and such dependent child were covered for benefits at the time of your death).
• upon termination of your employment (providing your child was covered at the time of such termination or was born or placed for adoption while the COBRA provisions were in effect.
• upon your divorce or separation.
• upon the date your eligibility ceases due to retirement or any reason other than gross misconduct.
• the date your dependent child ceases to be a dependent (due to age, change in student status, etc. – see definition on page 1).
• Your spouse and your dependent children (where applicable) will have the option to continue their Group Health Benefits for a period up to 36 months.

Termination of COBRA Benefits

The Group Health coverage under COBRA will automatically cease if:

Self payments are not received when due.

You or any of your dependents become covered under another Group Health Plan (including Medicare).

A divorced spouse or widow remarries and becomes covered under another Group Health Plan.

You return to work for an Employer who is obligated to make contributions on your behalf.

Notification and Filings

In the event your employment is terminated for any reason other than gross misconduct, you should immediately notify the Fund Office if you wish to continue your Group Health Benefits. You will then be furnished with the forms and instructions as to how to continue your health benefits on a direct payment basis.

You (or any family member) must also notify the Fund Office of any divorce, legal separation, or change in a dependent’s child’s status (i.e. attainment of maximum age, change in student classification, marriage) which might result in loss of Group Health Benefits.

Under the new law, you or one of the family members have up to 60 days to file your election with the Fund Administrator for continuation of Group Health Coverage on a direct payment basis and another 45 days to make the required self payments.

Group Health Benefits

You or an eligible dependent, who qualified under the direct payment provisions set forth above, will be covered for Empire Blue Cross Blue Shield Hospital and Medical Benefits, plus supplemental Comprehensive Medical, Prescription Drug, Dental and Vision Benefits in effect on the date such coverage was scheduled to be terminated. There will be no continuation of the Employee Group Life Insurance, or Employee Weekly Supplemental Disability Benefits under this section of the Plan.

The amount of the direct payment will be based on the group rate for your particular class of benefits. These costs may change from time to time, based on the actual claim experience of the group. In any event, the amount of the monthly Direct Payment required to maintain your Health Benefits or that of your dependents will be furnished upon request.

Termination of COBRA Due To Coverage Under Another Plan

As you may know, COBRA coverage may be terminated for any participant when he or she becomes covered under another group health plan, even when that plan contains a preexisting condition exclusion or limitation. However, under the provisions of the Health Insurance Portability and Accountability of 1996, those plans that do have preexisting condition limitations must now conform to regulations which limit the circumstances under which plan s can apply the exclusions for a preexisting condition. This new law limits the preexisting condition exclusion period to a maximum period of twelve months, and also requires all plans to give credit for any prior period of continuous health coverage under another plan. A period of prior coverage is not considered continuous if the individual had no health coverage for a 63 day period between his or her "old plan" and the new plan. Where coverage is not continuous, no credit for prior coverage is required. Where coverage is continuous, the period of coverage under the old plan will be credited to satisfy the waiting period for pre existing conditions.

Example

Joe Participant has been covered under the group health plan for 20 months. When he terminates employment, he elects COBRA continuation coverage under the plan. At the time that he elects COBRA coverage, he has a specific health problem. At the end of the fifth month of his COBRA continuation coverage period, he gets a new job and enrolls in his new employer’s group health plan. As permitted by law, the new plan excludes coverage for preexisting conditions, including Joe’s specific health problem, for 12 months. In determining whether Joe is subject to the 12 month preexisting condition exclusion period, his new employer must credit him with the 25 months of coverage he had under his prior employer’s plan (because there is no break in coverage of 63 days). Since Joe had been covered under his first employer’s group health plan for at least 12 months immediately prior to becoming covered under his new employer’s plan, he is not subject to the preexisting condition exclusion. For this reason, Joe’s prior plan may terminate his COBRA coverage.