Hawaii Employer-Union Health Benefits Trust Fund

This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan when coverage under the Plan would normally cease. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. COBRA and the description of COBRA continuation coverage set forth in this notice applies only to the group health plan benefits offered under the Plan (medical, prescription drug, dental, and/or vision benefits) and does not apply to any other benefits offered under the Plan or by the EUTF such as life insurance.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you in certain circumstances when you would otherwise lose your group health coverage under the Plan. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage under the Plan. This notice does not fully describe COBRA continuation coverage rights or other rights you may have under the Plan. For additional information about your rights and obligations under the Plan and under federal law, you should review the COBRA information on the Plan’s website at eutf.hawaii.gov or contact the EUTF. The Plan provides no greater COBRA continuation coverage rights than what COBRA requires, and nothing in this notice should be understood to expand your rights beyond what COBRA requires.

You may have other options available to you when you lose group health coverage. For example, you may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

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 occurs and any required notice of that event is provided to the EUTF, COBRA continuation coverage must be offered to each person who loses or will lose coverage under the Plan who is a “Qualified Beneficiary”. You, your spouse, and your dependent children could become Qualified Beneficiaries, and would be entitled to elect COBRA continuation coverage, if coverage under the Plan is lost because of the Qualifying Event.

Also, if a child is born to you or adopted by or placed for adoption with you during a period of COBRA continuation coverage, or if you are required to provide coverage to a child under the terms of a Qualified Medical Child Support Order (QMCSO), that child may become a Qualified Beneficiary. This is discussed in greater detail later in this notice. 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 and entitled to elect COBRA continuation coverage if you lose your group health coverage under the Plan because either one of the following Qualifying Events happens:

• Your hours of employment are reduced making you ineligible for group health coverage (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 (including retirement).

If you are the spouse of an employee, you will become a Qualified Beneficiary and entitled to elect COBRA continuation coverage if you lose your group health coverage under the Plan because any of the following Qualifying Events happens:

• Your spouse dies;
• Your spouse’s hours of employment are reduced making the employee ineligible for group health coverage;
• Your spouse’s employment ends; or
• You become divorced from your spouse.
  • If an employee cancels coverage for the spouse in anticipation of a divorce, and a divorce later occurs, then the divorce will be considered the Qualifying Event, even though the ex-spouse is not covered under the Plan on the date of the divorce. If the ex-spouse notifies the EUTF within 60 days after the divorce is final, then COBRA continuation coverage may be available for the period after the divorce is finalized.

Your dependent children who are enrolled in the Plan will become Qualified Beneficiaries and entitled to elect COBRA continuation coverage if they lose coverage under the Plan because any of the following Qualifying Events happen:

• The parent-employee dies;
• The parent-employee’s hours of employment are reduced making the parent-employee ineligible for group health coverage;
• The parent-employee’s employment ends;
• The parents become divorced; or
• The child stops being eligible for coverage under the Plan as a “dependent child”.

The Plan will offer COBRA continuation coverage to Qualified Beneficiaries only after the EUTF has been notified that a Qualifying Event has occurred. When the Qualifying Event is the end of employment (including retirement) or reduction of hours of employment making the employee ineligible for group health coverage, or the death of the employee, your employer must notify the EUTF of the Qualifying Event.

For the other initial Qualifying Events (e.g., divorce of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child), you must provide the EUTF with notice of the Qualifying Event within 60 days after the later of 1) the date of the Qualifying Event or 2) the date of the loss of coverage under the Plan.

You must provide this notice in writing by appropriately completing the attached “Notice of a COBRA-Related Event”. You must follow the procedures specified below in the section entitled “Notice Procedures” and you must return the signed and dated form along with appropriate supporting documentation of the initial Qualifying Event within the 60-day time period described above. The section entitled “Notice Procedures” also describes what the Plan will accept as appropriate supporting documentation of the initial Qualifying Event. Oral notice, including notice by telephone, is not acceptable, and electronic notice by e-mail is not acceptable. You may return the “Notice of a COBRA Related Event” to the EUTF by mail, by fax or by hand-delivery according to the procedures specified below in the section entitled “Notice Procedures”.

Once the EUTF receives timely notice that an initial Qualifying Event has occurred, COBRA continuation coverage will be offered to each of the Qualified Beneficiaries. Each Qualified Beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their covered spouses, and parents may elect COBRA continuation coverage on behalf of their qualifying children. For each Qualified Beneficiary who timely elects COBRA continuation coverage, COBRA continuation coverage will begin on the later of the date of the Qualifying Event or the date of the loss of group health coverage under the Plan.

Qualified Beneficiaries may be enrolled in one or more group health care components of the Plan at the time a Qualifying Event occurs. If a Qualified Beneficiary is entitled to elect COBRA continuation coverage as a result of the Qualifying Event, he or she may elect COBRA continuation coverage under any or all of the group health care components of the Plan under which he or she was covered on the day before the occurrence of the Qualifying Event. For example, if a Qualified Beneficiary was covered under the medical and dental components of the Plan on the day before the Qualifying Event occurred, he or she may elect COBRA continuation coverage under the medical component only, the dental component only, or under both the medical and dental components. However, if the Qualified Beneficiary was not covered under the dental component of the Plan on the day before the Qualifying Event occurred, then the Qualified Beneficiary would not be entitled to elect COBRA continuation coverage under the dental component of the Plan.

Qualified Beneficiaries who are entitled to elect COBRA continuation coverage may do so even if, on or before the day they elect COBRA continuation coverage, they have other group health plan coverage or are entitled to benefits under Medicare (under Part A, Part B or both). However, a Qualified Beneficiary’s COBRA continuation coverage will automatically end if, after electing COBRA continuation coverage, he or she becomes covered under another group health plan or becomes entitled to benefits under Medicare (under Part A, part B or both).

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 may last for only up to a total of 18 months. When the Qualifying Event is the death of the employee, the covered employee’s divorce, or a dependent child losing eligibility as a dependent child, COBRA continuation coverage may last for up to a total of 36 months. The COBRA continuation coverage periods described above are maximum coverage periods. COBRA coverage can end before the maximum coverage period described in this Notice for several reasons.

There are three ways in which this 18-month period of COBRA continuation coverage (resulting from a reduction in hours or employment or termination of employment) can be extended.

If a Qualified Beneficiary in your family covered under the Plan is determined by the Social Security Administration to be disabled as of the Qualifying Event or at any time during the first 60 days of COBRA continuation coverage and you notify the EUTF in writing in a timely fashion, you and all of the Qualified Beneficiaries in your family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum COBRA coverage period of 29 months. This extension of the COBRA coverage period is available only for Qualified Beneficiaries who are receiving COBRA continuation coverage because of a Qualifying Event that was the covered employee’s reduction in hours of employment or termination of employment.

The additional 11 months of COBRA continuation coverage will be available as long as the disabled individual continues to be disabled. However, if the Social Security Administration subsequently makes a final determination that the disabled individual is no longer disabled, and the cessation of disability occurs before then end of the 11th month of additional COBRA coverage, the COBRA Plan Administrator(s) will terminate the COBRA continuation coverage for all Qualified Beneficiaries as of the first day of the month that is more than 30 days after the date of cessation.

You must provide the EUTF COBRA Coordinator with notice of the Social Security Administration’s disability determination within 60 days after the latest of:

• The date of the Social Security Administration’s disability determination;
• The date of the covered employee’s termination of employment or reduction in hours of employment; or
• The date on which the Qualified Beneficiary loses (or would lose) coverage under the Plan as a result of the covered employee’s termination of employment or reduction in hours of employment.

In addition, in order to be entitled to the disability extension you must provide the COBRA Plan Administrator(s) with notice of the Social Security Administration’s disability determination within 18 months after the covered employee’s termination of employment or reduction in hours of employment. If you provide notice to the COBRA Plan Administrator(s) of the Social Security Administration’s disability determination at a date more than 18 months after the covered employee’s termination of employment or reduction in hours of employment, you will not be entitled to the disability extension, even if you provided the notice within 60 days after receiving the Social Security Administration’s disability determination.

You must provide notice of the disability determination in writing by appropriately completing the attached “Notice of a COBRA-Related Event.” You must follow the procedures specified below in the section entitled “Notice Procedures” and you must return the signed and dated form along with appropriate supporting documentation of the Social Security Administration’s disability determination within the time period described above.

If your family experiences another Qualifying Event while receiving 18 (or 29) months of COBRA continuation coverage resulting from the covered employee’s termination of employment or reduction in hours of employment (or during the disability extension period following either of these Qualifying Events), the spouse and dependent children in your family who are receiving COBRA continuation coverage can get up to 18 additional months of COBRA continuation coverage, for up to a maximum of 36 months of COBRA continuation coverage under these events:

• The employee or former employee dies;
• The spouse gets divorced; or
• If the dependent child stops being eligible under the Plan as a dependent child.

For second Qualifying Events, you must provide the COBRA Plan Administrator(s) with written notice of the second Qualifying Event within 60 days after the second Qualifying Event occurs. You must follow the procedures specified below in the section entitled “Notice Procedures” and you must return the signed and dated form along with appropriate supporting documentation within the time period described above. Failure to notify the Plan in a timely fashion may jeopardize an individual’s rights to extended COBRA coverage.

Note that Medicare entitlement is not a qualifying event under this Plan because it does not result in loss of coverage. As a result, Medicare entitlement following a termination of coverage or reduction in hours will not extend COBRA to 36 months for spouses and dependents who are qualified beneficiaries.

If a Qualifying Event that is a termination of employment or reduction of hours of employment occurs within 18 months after the covered employee becomes entitled to Medicare benefits (under Part A, Part B, or both), then the maximum coverage period for the spouse and dependent children (but not the employee) will be up to 36 months from the date the employee became entitled to Medicare benefits. 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 who lost coverage under the Plan due to the employee’s termination of employment can last up to 36 months after the date of the employee’s Medicare entitlement, which is equal to 28 months after the date of the Qualifying Event (36 months minus 8 months). However, in this situation, the covered employee’s maximum coverage period will be 18 months.

A child born to, or adopted by, or placed for adoption with a covered employee during a period of COBRA continuation coverage is considered to be a Qualified Beneficiary provided that, if the covered employee is a Qualified Beneficiary, the covered employee has elected COBRA continuation coverage for himself or herself. The newborn or adopted child’s COBRA continuation coverage begins when the child is enrolled in the Plan, whether under the special enrollment rights mandated by the Health Insurance Portability and Accountability Act (HIPAA) or during an open enrollment period, and the COBRA continuation coverage lasts as long as COBRA coverage lasts for other family members who have previously elected COBRA continuation coverage. To be enrolled in the Plan, the child must satisfy the otherwise applicable eligibility requirements of the Plan (for example, regarding attained age or student status).

A child of the covered employee who is receiving benefits under the Plan pursuant to a Qualified Medical Child Support Order (QMCSO) received by the EUTF during the covered employee’s period of employment with State or appropriate county, is entitled to the same rights under COBRA as an eligible dependent child of the covered employee, regardless of whether that child would otherwise be considered a dependent under the eligibility requirements of the Plan.

A qualified beneficiary generally has the same rights as similarly situated active employees to add or drop dependents, make enrollment changes during open enrollment, etc. Contact the EUTF COBRA Coordinator for more information.

Once COBRA Continuation Coverage has been elected, it may be cut short (terminated early) on the occurrence of any of the following events:

1. The date the group health plan no longer provides group health coverage to any of its employees;
2. The date the amount due for COBRA coverage is not paid in full and on time;
3. The date the Qualified Beneficiary becomes entitled to Medicare (Part A, Part B or both) after electing COBRA;
4. The date, after the date of the COBRA election, on which the Qualified Beneficiary first becomes covered under another group health plan (IMPORTANT: The Qualified Beneficiary must notify this Plan as soon as possible once they become aware that they will become covered under another group health plan, by contacting the EUTF COBRA Coordinator. COBRA coverage under this Plan ends on the date the Qualified Beneficiary is covered under the other group health plan).
5. During an extension of the maximum COBRA coverage period to 29 months due to the disability of the Qualified Beneficiary, the disabled beneficiary is determined by the Social Security Administration to no longer be disabled;
6. The date the Plan has determined that the Qualified Beneficiary must be terminated from the Plan for cause (on the same basis as would apply to similarly situated non-COBRA participants under the Plan).

Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/agencies/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.).

In order to protect your family’s rights, you must notify the EUTF and each COBRA Plan Carrier of any changes in the addresses of family members by submitting changes in writing. You should also keep a copy, for your records, of any notices or forms you send.

You must mail any applicable notices or forms described in this Notice to the EUTF at the following address:

You may fax any notices or forms described in this Notice to the EUTF at the fax number above. You may hand-deliver any notices or forms to the EUTF at the address above.

If you have questions regarding this Notice or your rights under COBRA, you may call the EUTF at the telephone number shown above. You may also view the EUTF’s “COBRA Notice” on the website at: eutf.hawaii.gov or find additional information about COBRA in the Reference Guide for Actives.

You must mail any applicable notices or forms described in this Notice to the EUTF at the address above. The carriers contact information is provided below:

You must provide notice to the EUTF of certain Qualifying Events and of other events that affect the continuation or duration of your COBRA continuation coverage. These Qualifying Events and other events were described in this notice and are also outlined below. You must provide this notice in writing by using the “Notice of a COBRA-Related Event” which follows these Notice Procedures. You must fully complete the “Notice of a COBRA-Related Event”, attach any required documentation specified below, and mail, fax or hand-deliver the signed and dated Notice to the EUTF.

Specifically, you must use this Notice to inform the EUTF of the following:

• Certain initial Qualifying Events: A divorce of the covered employee and the covered spouse; or a covered dependent child ceasing to be a dependent under the terms of the Plan;
• The occurrence of a second Qualifying Event after a Qualified Beneficiary has become entitled to COBRA continuation coverage with a maximum COBRA coverage period of 18 or 29 months; and
• The occurrence of the following event which may affect the continuation or duration of a Qualified Beneficiary’s COBRA continuation coverage after COBRA has been elected: The determination by the Social Security Administration that a Qualified Beneficiary who is entitled to COBRA continuation coverage with a maximum COBRA coverage period of 18 months is disabled at any time during the first 60 days of COBRA continuation coverage.

Please note that you do not need to notify EUTF of an initial Qualifying Event that is the end of employment or reduction of hours of employment or the death of the employee. Instead your employer must notify the EUTF of these three initial Qualifying Events.

The following individuals may provide the Notice of the initial Qualifying Event:

• The covered employee (that is, the employee or former employee who is or was covered under the Plan);
• A Qualified Beneficiary with respect to the initial Qualifying Event being reported in the Notice; or
• A representative acting on behalf of the covered employee or a Qualified Beneficiary. A power of attorney or court order will be required before action is taken on any document submitted by a representative.

A Notice of an initial Qualifying Event provided by any of these individuals will satisfy any responsibility to provide notice on behalf of all qualified beneficiaries who lost coverage under the Plan due to the Qualifying Event identified in the Notice.

When the initial Qualifying Event is a divorce of the employee and spouse or a dependent child’s losing eligibility for coverage as a dependent child under the terms of the Plan, you must notify the EUTF (or, for Active Employees only, your Employer or EUTF) in writing within 60 days after the later of (1) the date of the Qualifying Event or (2) the date on which the Qualified Beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the Qualifying Event.

If the initial Qualifying Event is a dependent child’s loss of eligibility under the terms of the Plan, you must provide satisfactory documentation of the date of the Qualifying Event to the EUTF when requested by the EUTF.

When you wish to give notice of a second Qualifying Event (such as the covered employee’s death, a divorce of the employee and spouse, or a dependent child’s loss of eligibility under the terms of the Plan) following an initial Qualifying Event that is the end of employment or reduction of hours of employment, you must notify the COBRA Coordinator in writing within 60 days after the later of (1) the date of the second Qualifying Event; or (2) the date on which the Qualified Beneficiary (that is, the covered spouse or dependent child) would lose coverage under the terms of the Plan as a result of the second Qualifying Event (if this Qualifying Event had occurred while the Qualified Beneficiary was still covered under the Plan). You must provide notice of a second Qualifying Event by using the Plan’s “Notice of a COBRA-Related Event”.

If you provide the COBRA Coordinator with a written notice of a second Qualifying Event that does not contain the information required by these Notice Procedures, the Plan will nevertheless consider your notice to be timely if all of the following conditions are met:

• The notice is mailed, faxed or hand-delivered to the individual and address specified above;
• The notice is provided by the deadline specified above;
• From the written notice provided, the COBRA Plan Administrator(s) is able to determine that the notice relates to the Plan;
• From the written notice provided, the COBRA Coordinator is able to identify the covered employee and the Qualified Beneficiary(ies), the nature of the second Qualifying Event and the date on which the second Qualifying Event occurred; and
• The notice is supplemented in writing with the additional information and/or documentation necessary to meet the Plan’s requirements. If the Plan requests additional information or documentation, you must provide the additional information or documentation within 15 business days after the COBRA Coordinator’s written or oral request to provide the information (or, if later, by the 60-day deadline for giving notice of a second Qualifying Event described above). If all of these conditions are met, the Plan will treat the notice of a second Qualifying Event as having been provided in a timely manner.

When the SSA determines that a Qualified Beneficiary is disabled and you wish to qualify for the disability extension of the 18-month COBRA coverage period, you must provide the COBRA Coordinator with the “Notice of a COBRA-Related Event” within 60 days after the latest of (1) the date of the SSA’s disability determination, (2) the date of the covered employee’s termination of employment or reduction in hours of employment, or (3) the date on which the Qualified Beneficiary would lose coverage under the terms of the Plan as a result of the termination of employment or reduction in hours of employment. In addition, you must provide the SSA’s determination of disability within 60 days after the covered employee’s termination of employment or reduction in hours of employment. You must provide notice of the SSA’s determination of disability by using the Plan’s “Notice of a COBRA-Related Event”.

When the SSA determines that a disabled Qualified Beneficiary is no longer disabled, the Qualified Beneficiary must provide the COBRA Plan Administrator(s) with the “Notice of a COBRA-Related Event” in order to advise the Plan of the cessation of disability. You must provide this Notice within 30 days after the date of the SSA’s determination that the disabled Qualified Beneficiary is no longer disabled. You must include a copy of the SSA’s determination of the cessation of disability with your “Notice of a COBRA-Related Event.”

If the SSA’s determination of the cessation of disability is dated prior to the initial maximum COBRA coverage period of 18 months, COBRA continuation coverage for all Qualified Beneficiaries will terminate at the end of the 18th month of COBRA continuation coverage.

If the SSA’s determination of the cessation of disability is dated after the initial maximum COBRA coverage period of 18 months, COBRA continuation coverage for all Qualified Beneficiaries will terminate at the first day of the full month after the date of the SSA’s determination that the disabled Qualified Beneficiary is no longer disabled.

If you fail to give the EUTF COBRA plan carriers timely and proper notice of the Social Security Administration’s determination that the disabled Qualified Beneficiary is no longer disabled, the COBRA Plan Administrator(s) reserves the right to terminate COBRA continuation coverage for all Qualified Beneficiaries retroactive to the date COBRA continuation coverage would have terminated if you had given timely and proper notice of the SSA’s determination that the disabled Qualified Beneficiary is no longer disabled. The COBRA Plan Administrator(s)/EUTF also reserves the right to require repayment to the COBRA Plan Administrator(s)/EUTF of the cost of all benefits provided or paid after the date COBRA continuation coverage would have terminated, regardless of whether or when you give notice that the disabled Qualified Beneficiary is no longer disabled.

Guidance and other information are available on the Department of Labor, Internal Revenue Service and Department of Health and Human Services web sites:

For general information regarding your plan’s COBRA coverage you can contact the EUTF at (808) 586-7390, toll free 1-800-295-0089, via email at [email protected] or by mail at 201 Merchant Street, Suite 1700, Honolulu HI 96813.

The person completing this form should do the following:

1. Complete the form using blue or black ink. Do not use pencil. Write or print legibly.
2. Fill in the date that the event you are reporting occurred. Either show the date in full, for example, January 5, 2018 or use a month/day/year format, for example 1/5/2018.
3. Check the box corresponding to the Qualifying Event or other COBRA-related event you are reporting.
4. List the names of all family members who; (1) are or were covered under the Plan and (2) whose coverage under the Plan may be affected by the date you are reporting. Be sure to include your own name if it is appropriate.
5. Be sure to sign and date the form.
6. Indicate the name of the employee covered under the Plan. Show the employee’s first name, middle initial and last name. Be sure to write or print legibly.
7. Indicate a current telephone number where the COBRA COORDINATOR may call you if there are any questions regarding your Notice.
8. Indicate the current mailing address where the COBRA COORDINATOR should send the COBRA Election Form or other correspondence. If you are reporting an event that affects the coverage of any family member who does not reside with you (for example a child away at school), please note their current mailing address on the back of the form.
9. Attach appropriate documentation to verify the date of the event you are reporting. The “COBRA Notice” on the Plan’s website provides examples of appropriate documentation for the different events.
10. Review the form to make sure it is complete. If you have any questions about completing the form, you may contact the EUTF by phone at (808) 586-7390 or email at [email protected].
11. After you have signed and dated the form, make a copy of the completed form and keep it in a safe place for future reference.
12. Return the completed form to the COBRA COORDINATOR at the address shown on the top of the notice. You may return the Notice by mail, by fax, or you may deliver it by hand. You may fax the Notice to the COBRA COORDINATOR at (808) 586-2161. You may hand-deliver the notice to the COBRA COORDINATOR at 201 Merchant Street, Suite 1700, Honolulu, HI 96813.
13. If you mail the Notice, be sure to affix sufficient postage to the envelope. Timely delivery of the Notice is important. If the Postal Service returns your Notice because of insufficient postage, you may not be able to re-mail the notice in a timely manner. If your Notice is late, you will forfeit your rights under COBRA and you will not be entitled to elect or extend COBRA continuous coverage.
14. If you fax the Notice, be sure to keep a copy of the fax transmittal report showing the date and time the Notice was transmitted, the fax number that received the Notice and the status of the fax transmission.

• Notice of COBRA Related Event
• Change of Address Form