COBRA Continuation Coverage Election Notice
This COBRA CONTINUATION COVERAGE ELECTION NOTICE PAMPHLET contains important information and instructions regarding your health benefits continuation coverage under COBRA. You have recently experienced a COBRA qualifying event and may qualify for temporary continuation of health benefits under COBRA. If you fail to comply with these instructions, you may lose your eligibility for COBRA continuation coverage.
COBRA Continuation Coverage Election Notice
This COBRA election notice contains important information about rights to temporarily continue your health care coverage in the Hawaii Employer-Union Health Benefits Trust Fund’s (EUTF) group health plan(s) (the Plan), as well as other health coverage alternatives that may be available to you, including coverage through the Health Insurance Marketplace at www.healthcare.gov or call the Marketplace Help Center at 1-800-318-2596. You may be able to get coverage through the Health Insurance Marketplace that costs less than COBRA continuation coverage. Please read the information in this notice very carefully before you make your decision. If you choose to elect COBRA continuation coverage, you should use the election form attached.
Please read the information contained in this notice very carefully. The pronouns “you” and “your” refer to each of the individuals identified on the Continuation Coverage (COBRA) Election Form included with this notice. This notice provides important information concerning your rights under a federal law known as COBRA, and what you have to do to continue your health care coverage under the Plan.
If you have any questions concerning your rights to coverage under COBRA, contact the COBRA Coordinator:
Hawaii Employer-Union Health Benefits Trust Fund
Attn: COBRA COORDINATOR
201 Merchant Street Suite 1700 Honolulu, HI 96813
Telephone: (808) 586-7390 or Toll Free: 1 (800) 295-0089
The party responsible for administering COBRA continuation coverage, and their address and/or telephone number is subject to change. For the most recent contact information and information about your COBRA rights, check the EUTF’s website at www.eutf.hawaii.gov. A copy of the COBRA General Notice was provided to you when you first enrolled with the EUTF. If you do not have a current copy, you may request one at no charge from the EUTF or download it from the EUTF’s website at www.eutf.hawaii.gov.
Why am I getting this Notice?
Federal law requires that most group health plans (including this Plan) give employees and their families the opportunity to continue their health care coverage through COBRA continuation coverage when there’s a “qualifying event” that would result in a loss of coverage under an employer’s plan.
What is COBRA continuation coverage?
COBRA continuation coverage is the same health coverage that the Plan gives to other participants or beneficiaries who aren’t getting continuation coverage. Each “qualified beneficiary” (described below) who elects COBRA continuation coverage will have the same rights under the Plan as other participants or beneficiaries covered under the Plan.
Other Coverage Options
Instead of enrolling in COBRA continuation coverage, there may be other more affordable coverage options for you and your family, through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options.
In the Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums right away, and you can see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll. Being eligible for COBRA does not limit your eligibility for coverage or for a tax credit through the Marketplace. Additionally, you may qualify for a special enrollment opportunity for another group health plan for which you are eligible (such as a spouse’s plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days.
When you lose job-based health coverage, it’s important that you choose carefully between COBRA continuation coverage and other coverage options, because once you’ve made your choice, it can be difficult or impossible to switch to another coverage option.
Continuation Coverage (COBRA) Election Form Instructions
Each person (“Qualified Beneficiary”) listed for each COBRA option on the COBRA Election Form is entitled to elect COBRA continuation coverage, which will temporarily continue group health care coverage under the Plan until the date noted on the cover letter. The qualified beneficiaries listed on the COBRA Election Form are the only persons eligible to enroll in COBRA.
INSTRUCTIONS: To elect COBRA continuation coverage, you MUST complete the enclosed COBRA Election Form for yourself and your dependents who want COBRA coverage and return it signed and dated form to us. Under federal law, you have an election period of 60 days (starting on the later of the date you are furnished the election notice or the date you would lose coverage) to choose whether or not to elect COBRA continuation coverage under the Plan. You may mail, fax or hand-deliver the completed COBRA Election Form.
By mail or hand-delivery:
Hawaii Employer-Union Health Benefits Trust Fund
201 Merchant Street Suite 1700
Honolulu, Hawaii 96813
By fax: (808) 586-2161
COBRA continuation coverage may end before the date noted above in certain circumstances, like failure to pay premiums in full or on time, fraud, or the individual becomes covered under another group health plan or Medicare after electing COBRA.
If you want COBRA coverage, you must complete this COBRA Election Form and return it to us by the reply deadline date stated on the COBRA election notice letter. If sent by mail, it must be post-marked no later than the reply deadline date. If you fax or deliver the completed form, it must arrive at the EUTF no later than the reply deadline date. The following are not acceptable as COBRA elections and will not preserve your COBRA continuation coverage rights: oral communications regarding COBRA coverage, including in-person or telephone statements about an individual’s desire to elect COBRA; and electronic or e-mail communications.
IF YOU WANT COBRA COVERAGE BUT DO NOT SUBMIT A COMPLETED COBRA ELECTION FORM BY THE REPLY DEADLINE DATE (by 60 calendar days from the later of the date you are furnished the COBRA election notice or the date you would lose coverage), YOU WILL LOSE YOUR RIGHT TO ELECT COBRA CONTINUATION COVERAGE.
If you reject (waive) COBRA continuation coverage before the due date, you may change your mind as long as you submit a completed COBRA Election Form by the due date. However, if you change your mind after first rejecting COBRA continuation coverage, your COBRA continuation coverage will begin not on the first day you lost coverage, but (after the appropriate insurance carrier receives your first COBRA premium payment) on the date you furnish the completed COBRA Election Form.
Specific Instructions about your election notice form
- Notification Date: The notification date is the date you are furnished the election notice.
- Reply Deadline: The reply deadline is the date your COBRA Election Form must be received by the EUTF. You are given an election period of 60 days starting on the later of the date you are furnished the election notice or the date you would lose coverage.
- First Day of Coverage: Your first day of coverage is the day after you were terminated from the EUTF group health plan.
- Your last day of coverage can be moved up if specific events occur. Please read the enclosed election notice document for specific information.
- On the COBRA Election Form itself:
- Qualifying Event: This is the COBRA qualifying event that, by Federal law, requires your employer to provide continued health benefits coverage at your expense.
- Date of Qualifying Event: This is the date of your COBRA qualifying event. Your COBRA continuation coverage will begin the day after your last date of active coverage. If your dependents were covered under the Plan on the last date of active coverage, they are also eligible for COBRA continuation coverage.
Part A: COBRA Participation
- If you decide to waive your right to COBRA, check the appropriate box, sign the form and submit it to the Plan.
- If any of your qualified dependents chooses to enroll individually, complete the individual election forms provided for each family member choosing to enroll separately. You may still enroll the rest of the family under your or your spouse’s enrollment (as applicable).
- If a family member lives separately (in school) and chooses to enroll separately, please provide an address to ensure that the proper documents are sent to the correct member.
Part B: COBRA Plan Elections and Payment Options
- The plans and qualified beneficiaries listed are those that were active on the last day of coverage. You may only enroll in those plans in which you were enrolled on the last day of coverage.
Part C: Participant Signature
- Please complete this form by signing the form. Failure to submit a complete, signed form may cause you to become ineligible for COBRA benefits.
Important Information About Your COBRA Continuation Coverage Rights
What is COBRA continuation coverage?
Federal Law requires that most group health care plans (including this Plan) give employees and their families the opportunity to continue their health care coverage when there is a “qualifying event” that would result in a loss of coverage under an employer’s plan. Depending on the type of qualifying event, “qualified beneficiaries” can include the employee (or the retired employee) covered under the group health plan, the covered employee’s spouse [or domestic partner or civil union partner], and the dependent children of the covered employee.
COBRA Continuation coverage is the same coverage that the Plan offers to other participants or beneficiaries under the Plan who are not receiving COBRA continuation coverage. Each qualified beneficiary who elects COBRA continuation coverage will have the same rights under the Plan as other participants or beneficiaries covered under the Plan, including open enrollment and special enrollment rights. Covered employees and retirees may elect COBRA on behalf of their spouses, and covered parents/legal guardians may elect COBRA for a minor child.
How long will COBRA continuation coverage last?
In the case of a loss of coverage due to end of employment or reduction in hours of employment, coverage generally may be continued for up to a total of 18 months from the date of the qualifying event.
In the case of a loss of coverage due to an employee’s death, or divorce, or a dependent child ceasing to be a dependent under the terms of the Plan, coverage may be continued for a spouse and dependents who are qualified for up to a total of 36 months.
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 may last for up to 36 months after the date of Medicare entitlement. This notice shows the maximum period of COBRA continuation coverage available to the qualified beneficiaries.
Once COBRA continuation coverage has been elected, it may be cut short (terminated early) on the occurrence of any of the following events:
- The date the amount due for COBRA coverage is not paid in full and on time;
- The date, after electing COBRA continuation coverage, on which a qualified beneficiary first becomes covered under another group health plan. IMPORTANT: The Qualified Beneficiary must notify this EUTF Plan as soon as possible once they become aware that they will become covered under another group health plan. COBRA coverage under this Plan ends on the date the Qualified Beneficiary is covered under the other group health plan;
- The date, after electing COBRA continuation coverage, a qualified beneficiary becomes entitled to Medicare benefits (under Part A, Part B, or both);
- The date the group heath plan ceases to provide group health plan to any of its employees;
- 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; or
- COBRA Continuation coverage may also be terminated for any reason the Plan would terminate coverage of non- COBRA participants under the plan (such as fraud).
How can you extend the length of COBRA continuation coverage?
If you elect COBRA continuation coverage, an extension of the maximum period of coverage may be available if a qualified beneficiary is disabled or a second qualifying event occurs. You must notify the COBRA Coordinator of a disability or a second qualifying event in order to extend the period of continuation coverage.
Failure to provide notice of a disability or second qualifying event may affect the right to extend the period of COBRA continuation coverage. The written notice can be sent via first class mail or hand-delivered to EUTF and is to include your name, the qualifying event, the date of the event and appropriate documentation in support of the qualifying event, such as divorce documents or a copy of the written Social Security Administration disability determination.
Extension of COBRA due to Disability
An 11-month extension of coverage may be available if any of the qualified beneficiaries is determined under the Social Security Act (SSA) to be disabled. The disability has to have started at some time on or before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of COBRA continuation coverage. You must notify EUTF within 60 days of the date of the SSA’s disability determination if you want to extend your COBRA continuation coverage. Failure to provide timely notice of a disability may affect the right to extend the period of COBRA continuation coverage.
Each qualified beneficiary who has elected COBRA continuation coverage will be entitled to the 11-month disability extension if one of them qualifies. If the qualified beneficiary is determined to no longer be disabled under the SSA, you must notify the Plan of that fact within 30 days after that determination.
You must provide notice of the disability determination in writing. Oral notice, including notice by telephone, fax or email is not acceptable. If you do not adhere to these instructions or if you fail to provide written notice to the EUTF within the 60-day notice period described above, you and any other qualified beneficiaries will NOT be entitled to the disability extension of COBRA continuation coverage.
Extension of COBRA due to a Second Qualifying Event
An 18-month extension of coverage will be available to spouses and dependent children who elect COBRA continuation coverage if a second qualifying event occurs during the first 18 months of COBRA continuation coverage. The maximum amount of COBRA continuation coverage available when a second qualifying event occurs is 36 months. Such second qualifying events may include the death of a covered employee, divorce or separation from the covered employee, or a dependent child’s ceasing to be eligible for coverage as a dependent under the Plan. These events can be a second qualifying event only if they would have caused the qualified beneficiary to lose coverage under the Plan if the first qualifying event had not occurred.
Medicare entitlement is not a qualifying event under this plan. As a result, Medicare entitlement following termination of coverage or reduction in hours will not extend COBRA to 36 months for dependents who are qualified beneficiaries.
You must notify the Plan within 60 days after a second qualifying event occurs if you want to extend your COBRA continuation coverage. Failure to provide timely notice of a second qualifying event may affect the right to extend the period of COBRA continuation coverage.
Medicare Extension for Spouse and Dependent Children
When the Qualifying Event is the end of employment or reduction of the member’s hours of employment, and the member became entitled to Medicare benefits less than 18 months before the Qualifying Event, COBRA continuation coverage for Qualified Beneficiaries other than the member lasts until 36 months after the date of Medicare entitlement. For example, if a covered member 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). Otherwise, when the Qualifying Event is the end of employment or reduction of the member’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months.
How can you elect COBRA continuation coverage?
To elect COBRA continuation coverage, you must complete the COBRA Election Form and furnish it according to the directions on the form. Each qualified beneficiary has a separate right to elect COBRA continuation coverage. For example, the employee’s spouse may elect COBRA continuation coverage even if the employee does not. COBRA continuation coverage may be elected for only one, several, or for all dependent children who are qualified beneficiaries. A parent may elect to continue coverage on behalf of any dependent children. The employee or the employee’s spouse can elect COBRA continuation coverage on behalf of all of the qualified beneficiaries.
In considering whether to elect COBRA continuation coverage, you should take into account that you have special enrollment rights under Federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within 30 days after your group health coverage ends because of the qualifying event listed above. You will also have the same special enrollment right at the end of CORBA continuation coverage if you get COBRA continuation coverage for the maximum time available to you.
How much does COBRA continuation coverage cost?
Generally, each qualified beneficiary may be required to pay the entire cost of COBRA continuation coverage. The amount a qualified beneficiary may be required to pay may not exceed 102 percent (or, in the case of an extension of COBRA continuation coverage due to a disability, 150 percent) of the cost to the group health plan (including both employer and employee contributions) for coverage of a similarly situated plan participant or beneficiary who is not receiving COBRA continuation coverage. The required payment for each COBRA continuation coverage period for each option is described in this notice.
Note that the amount of COBRA premiums is subject to change in the future. You will be notified of any COBRA premium rate changes. If you choose to elect COBRA continuation coverage, you don’t have to send any payment with the Election Form, but read the important information on First Payment and Periodic Payment below.
When and how must payment for COBRA continuation coverage be made?
First payment for COBRA continuation coverage
If you elect COBRA continuation coverage, please do not send any payment with the initial Election Form. You must make your first payment directly to the respective COBRA Plan Administrator (insurance carrier) for COBRA continuation coverage no later than 45 days after the date of your COBRA election (This is the date the Election Notice is post- marked). If you do not make your first payment for COBRA continuation coverage in full within 45 days after the date of your election, you will lose all COBRA continuation coverage rights under the Plan. You are responsible for making sure that the amount of your first payment is correct. You may contact the appropriate insurance carrier to confirm the correct amount of your first payment. COBRA rates are also accessible on EUTF’s website at www.eutf.hawaii.gov.
Periodic payments for COBRA continuation coverage
After you make your first payment for COBRA continuation coverage, you will be required to make periodic COBRA payments for each subsequent coverage period. COBRA coverage periodic payments are due on the first day of the coverage month. The amount due for each coverage period for each qualified beneficiary is your responsibility to manage. The EUTF will not send periodic notices of payments due for these coverage periods. Payments must be coordinated between you and the appropriate insurance carrier(s).
Grace periods for periodic payments
Although periodic COBRA payments are due on the first day of the coverage month, you will be given a grace period of 30 days after the first day of the coverage period to make each payment. Your COBRA continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment.
However, if you pay a periodic payment later than the first day of the coverage period to which it applies, but before the end of the grace period for the coverage period, your coverage under the Plan may be suspended as of the first day of the coverage period and then retroactively reinstated (going back to the first day of the coverage period) when the periodic payment is received. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated.
If you fail to make a periodic COBRA payment before the end of the grace period for that coverage period, you will lose all rights to COBRA continuation coverage under the Plan.
Your first payment and all periodic payments for COBRA continuation coverage should be sent to the appropriate insurance carrier(s). The list included below is subject to change. Please contact the insurance carrier directly for billing assistance and to confirm their mailing address.
|Hawaii Dental Service (HDS)
700 Bishop Street 700, Honolulu, HI 96813
|Hawaii Medical Services Association (HMSA)
P.O. Box 860, Attn: Membership Services Department, Honolulu, HI 96808
|Kaiser Permanente (Kaiser)
711 Kapiolani Boulevard, Honolulu, HI 96813
|CVS Caremark (billing handled by ARM, Ltd.)
ARM Ltd., 814 W. Northwest Highway, Arlington Heights, IL 60004
|Vision Service Plan (VSP)
P.O. Box 997100, Sacramento, CA 95899
|1-800-400-4569 select #2|
For More Information
This notice does not fully describe COBRA continuation coverage or other rights under the Plan. More information about COBRA continuation coverage and your rights under the Plan is available in the applicable Reference Guide and in the “COBRA Notice” both of which are available on-line at the EUTF’s website at: www.eutf.hawaii.gov. Copies of these documents are also available at the EUTF at 201 Merchant Street, Suite 1700, Honolulu, Hawaii 96813.
If you have any questions concerning the information in this notice, your rights to coverage, or if you want a copy of the Reference Guide, you may contact the EUTF at: (808) 586-7390 or toll free at 1(800)295-0089.
For more information about your rights under COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, visit the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) website at www.dol.gov/ebsa or call their toll-free number at 1-866-444-3272. For more information about health insurance options available through a Health Insurance Marketplace, visit www.healthcare.gov. State and local government employees should contact HHS-CMS at www.cms.hhs.gov or NewCobraRights@cms.hhs.gov.
Keep Your Plan Informed of Address Changes
In order to protect your and your family’s rights, you should keep EUTF and each of your COBRA Plan Administrator(s) informed of any changes in your address and the addresses of family members. Submit any changes in writing. You should also keep a copy, for your records, of any notices and forms you send.
Instructions for COBRA Beneficiaries for Completing the “Secondary Notice of a COBRA-Related Event” form
The person completing this form should do the following:
- Complete the form using blue or black ink. Do not use pencil. Write or print legibly.
- Fill in the date that the event you are reporting occurred. Either show the date in full, for example, July 5, 2018 or use a month/day/year format, for example 7/5/2018.
- Check the box corresponding to the Qualifying Event or other COBRA -related event you are reporting.
- 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.
- Be sure to sign and date the form.
- 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.
- Indicate a current telephone number where the COBRA COORDINATOR may call you if there are any questions regarding your Notice.
- 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.
- 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.
- Review the form to make sure it is complete. If you have any questions about completing the form.
- 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.
- 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.
- 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.
- 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.
Call the plan coordinating each of your COBRA coverage(s) for plan specific questions.
Email the COBRA COORDINATOR at firstname.lastname@example.org if you have general questions. Include COBRA in the subject line so we can better prioritize our response.