Notification Responsibilities. In order to preserve rights under COBRA, Members and the Group must meet certain notification, election and payment deadline requirements. It is therefore very important that Members keep the Group informed of the current address of all persons who are or may become qualified beneficiaries. Members must inform the Group in writing within 60-days of divorce or legal separation, or a loss of eligibility of a child. The Group is responsible for notifying Members of the right to elect COBRA continuation due to any of the other qualifying events (for example, employee's death, termination of employment or reduction in hours or Medicare entitlement). Once the Group is notified or aware of a qualifying event, it sends Members information concerning continuation options, including the necessary COBRA continuation election forms. Members have 60-days from the later of the date of the qualifying event or the date of the Group's notice to a Member in which to make an election. As mentioned above, to be eligible for disability extension, a Member must provide the Group documentation of a Social Security disability determination within 60 days of the date it is made and while still within the 18-month COBRA continuation period following a termination or reduction of hours qualifying event. The determination must reflect that the Member was disabled for Social Security purposes at the time of the initial qualifying event or within the first 60-days of COBRA continuation. If a final determination is subsequently made that a Member is no longer disabled for Social Security purposes, the Member must provide the Group notice of that determination within 30 days of the date it is made. To be eligible for an extension of the 18-month continuation that follows a termination of employment/reduction in hours qualifying event (or a 29-month COBRA continuation period involving such a termination/reduction followed by a disability extension), Members must notify the Group. Notification must occur within 30 days of the occurrence of any of the following "second" qualifying events causing a loss of coverage within that 18-month (or 29-month) period: the Enrolled Employee's death; the Enrolled Employee dissolves his or her marriage (divorces), terminates his or her domestic partnership or legally separates; the Enrolled Employee becomes entitled to Medicare benefits; or the enrolled child loses eligibility as a child under this Contract. If Members wish to continue coverage, they must pay for it. Premiums generally will reflect the total cost of the group health care coverage and up to a 2 percent administration fee. For Members who receive COBRA Continuation Coverage due to a Social Security disability determination, premiums and administration fees will be up to 150 percent of the total cost for coverage for the period of the disability extension (provided the disabled individual is among those continuing coverage). Coverage ceases if timely premium payments are not made. Members have a maximum of 45 days from the date that the election form is mailed to the Group to submit the first payment. This first payment must retroactively cover any period of time after the date coverage was terminated. All subsequent payments are due on the first day of the month for which coverage is to be provided or within a 30-day grace period thereafter. If Members do not elect COBRA continuation coverage, coverage will end according to the terms of this Contract and We will not pay claims for services provided on and after the date coverage ends. If Members do not elect and exhaust COBRA continuation coverage, they may jeopardize their future eligibility for an individual plan. The federal government has adopted Medicare secondary payer (MSP) rules for determining which are the primary and secondary payers when a Member is covered under both Medicare and a group health plan. The rules depend on: whether the Medicare eligible person is active or retired (or the spouse of such person); whether the person has Medicare because of reaching age 65, disability or end stage renal disease; and the size of employer sponsoring the group health plan. In order to administer claims in compliance with the MSP rules, We need to know certain information. Accordingly, the Group must advise Us in writing within 30 days of a change in the number of employees as described in the following bulleted paragraphs: When the number of employees in a "current employment status" according to federal regulations increases to 20 or more, or decreases below 20. For purposes of this calculation, the Group will be considered to employ 20 or more employees if it has had 20 or more full- or part-time employees for each working day in each of 20 or more calendar weeks in the current calendar year or the preceding calendar year. When the number of employees in a current employment status increases to 100 or more or decreases below 100. For purposes of this calculation, the Group will be considered to employ 100 or more employees if it had 100 or more full- or part-time employees on 50 percent or more of its regular business days in the previous calendar year. When an employee retires and eligibility under this Contract allows retired employees to remain enrolled. The Group shall be responsible for claim amounts or penalties payable to the federal government resulting from noncompliance with the MSP rules caused by its failure to give Us notice of a Group size change under this provision.
Appears in 1 contract
Sources: Health Care Benefits Contract
Notification Responsibilities. In order to preserve rights under COBRA, Members and the Group must meet certain notification, election and payment deadline requirements. It is therefore very important that Members keep the Group informed of the current address of all persons who are or may become qualified beneficiaries. Members must inform the Group in writing within 60-days of divorce or legal separation, or a loss of eligibility of a child. The Group is responsible for notifying Members of the right to elect COBRA continuation due to any of the other qualifying events (for example, employee's death, termination of employment or reduction in hours or Medicare entitlement). Once the Group is notified or aware of a qualifying event, it sends Members information concerning continuation options, including the necessary COBRA continuation election forms. Members have 60-60- days from the later of the date of the qualifying event or the date of the Group's notice to a Member in which to make an election. As mentioned above, to be eligible for disability extension, a Member must provide the Group documentation of a Social Security disability determination within 60 days of the date it is made and while still within the 18-month COBRA continuation period following a termination or reduction of hours qualifying event. The determination must reflect that the Member was disabled for Social Security purposes at the time of the initial qualifying event or within the first 60-days of COBRA continuation. If a final determination is subsequently made that a Member is no longer disabled for Social Security purposes, the Member must provide the Group notice of that determination within 30 days of the date it is made. To be eligible for an extension of the 18-month continuation that follows a termination of employment/reduction in hours qualifying event (or a 29-month COBRA continuation period involving such a termination/reduction followed by a disability extension), Members must notify the Group. Notification must occur within 30 days of the occurrence of any of the following "second" qualifying events causing a loss of coverage within that 18-month (or 29-month) period: • the Enrolled Employee's death; • the Enrolled Employee dissolves his or her marriage (divorces), terminates his or her domestic partnership or legally separates; • the Enrolled Employee becomes entitled to Medicare benefits; or • the enrolled child loses eligibility as a child under this Contract. If Members wish to continue coverage, they must pay for it. Premiums generally will reflect the total cost of the group health care coverage and up to a 2 percent administration fee. For Members who receive COBRA Continuation Coverage due to a Social Security disability determination, premiums and administration fees will be up to 150 percent of the total cost for coverage for the period of the disability extension (provided the disabled individual is among those continuing coverage). Coverage ceases if timely premium payments are not made. Members have a maximum of 45 days from the date that the election form is mailed to the Group to submit the first payment. This first payment must retroactively cover any period of time after the date coverage was terminated. All subsequent payments are due on the first day of the month for which coverage is to be provided or within a 30-day grace period thereafter. If Members do not elect COBRA continuation coverage, coverage will end according to the terms of this Contract and We will not pay claims for services provided on and after the date coverage ends. If Members do not elect and exhaust COBRA continuation coverage, they may jeopardize their future eligibility for an individual plan. The federal government has adopted Medicare secondary payer (MSP) rules for determining which are the primary and secondary payers when a Member is covered under both Medicare and a group health plan. The rules depend on: • whether the Medicare eligible person is active or retired (or the spouse of such person); • whether the person has Medicare because of reaching age 65, disability or end stage renal disease; and • the size of employer sponsoring the group health plan. In order to administer claims in compliance with the MSP rules, We need to know certain information. Accordingly, the Group must advise Us in writing within 30 days of a change in the number of employees as described in the following bulleted paragraphs: • When the number of employees in a "current employment status" according to federal regulations increases to 20 or more, or decreases below 20. For purposes of this calculation, the Group will be considered to employ 20 or more employees if it has had 20 or more full- or part-time employees for each working day in each of 20 or more calendar weeks in the current calendar year or the preceding calendar year. • When the number of employees in a current employment status increases to 100 or more or decreases below 100. For purposes of this calculation, the Group will be considered to employ 100 or more employees if it had 100 or more full- or part-time employees on 50 percent or more of its regular business days in the previous calendar year. • When an employee retires and eligibility under this Contract allows retired employees to remain enrolled. The Group shall be responsible for claim amounts or penalties payable to the federal government resulting from noncompliance with the MSP rules caused by its failure to give Us notice of a Group size change under this provision.
Appears in 1 contract
Sources: Health Care Benefits Contract