Cobra Information. Health Insurance Provider Name: WellSystems Phone Number:

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1 Cobra Information Clipart of: Words to be continued Health Insurance Provider Name: WellSystems Phone Number: Dental & Vision Insurance Provider Name: MISD-Benefits Phone Number: Mesquite ISD Benefits Logo

2 DATE: June 29, 2017 TO: «Lname» «Fname» «Address» «City», «State» «Zip» FROM: RE: Mesquite ISD Benefits Office ENCLOSED GROUP INSURANCE INITIAL NOTIFICATION This notice applies to you and your eligible dependents should you elect coverage under the Mesquite ISD s group health, dental, and/or vision insurance plan(s). The notice outlines covered participants' potential future options and more importantly your notification obligations under the federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) should you ever lose your health, dental, and/or vision insurance in the future for certain reasons. Step #1: Step #2: Step #3: Please read the notice carefully. It is important that each individual covered under the plan read the notice and be familiar with the information. Should you add additional dependents in the future, notice to the covered employee and spouse at this time will be deemed notification to that newly covered dependent as well. If there is a covered dependent whose legal residence is not yours, you are required to provide in writing to the benefits department the appropriate address so a separate notice can be sent to them as well. Please use the COBRA Address Notification Form located at the end of this notice for this purpose. Should you ever move in the future, please use this form to keep us informed so you can receive future information if needed. Understand Your Notification Obligations! Under the terms of the group health, dental, and vision plan(s), only a spouse and eligible dependents, as defined by the insurance policy, can be covered under the plan. Therefore, under the rules of the policy and federal law, you or a covered spouse/dependent are required to notify the plan administrator of a divorce/legal separation or if a covered dependent ceases to be a dependent under the terms of the group plan. Please take special note of the section in the notice that details your notification obligations and the appropriate steps to take when making this notification. Should you fail to follow the outlined notification procedures; any available rights will be lost. Step #4: Place this notice in your records for future reference. Should you have any questions concerning this notice or your notification obligations, please do not hesitate to call the benefits department at

3 General Notice of COBRA Continuation Coverage Rights IMPORTANT INFORMATION PLEASE READ It is important that all covered individuals (employee, spouse, and dependent children, if able) take the time to read this notice carefully and be familiar with its contents. If there is a covered dependent whose legal residence is not yours, please provide written notification with the Address Notification Form to the benefits department so a notice can be sent to them as well. Under federal law, Mesquite ISD is required to offer covered employees and covered family members the opportunity for a temporary extension of health, dental, and/or vision coverage (called "Continuation Coverage") when coverage under the health, dental, and/or vision plan would otherwise end due to certain qualifying events. This notice is intended to inform all plan participants, in a summary fashion of your potential future options and obligations under the continuation coverage provisions of the COBRA law. Should an actual qualifying event occur in the future, the plan administrator will send you additional information and the appropriate election notice at that time. Please take special note, however, of your notification obligations which are highlighted at the bottom of this page! Qualifying Events For Covered Employee If you are the covered employee, you may have the right to elect this health, dental, and/or vision plan continuation coverage if you lose your group health, dental, and/or vision coverage because of a termination of your employment (for reasons other than gross misconduct on your part) or a reduction in your hours of employment. Qualifying Events For Covered Spouse If you are the covered spouse of an employee, you may have the right to elect this health, dental, and/or vision plan continuation coverage for yourself if you lose group health, dental, and/or vision coverage under Mesquite ISD because of any of the following reasons: 1. A termination of your spouse s employment (for reasons other than gross misconduct) or reduction in your spouse s hours of employment with Mesquite ISD; 2. The death of your spouse; 3. Divorce from your spouse; or 4. Your spouse becomes entitled to Medicare. Qualifying Events For Covered Dependent Children If you are the covered dependent child of an employee, you may have the right to elect continuation coverage for yourself if you lose group health, dental, and/or vision coverage under Mesquite ISD because of any of the following reasons: 1. A termination of your spouse s employment (for reasons other than gross misconduct) or reduction in your spouse s hours of employment with Mesquite ISD; 2. The death of the employee of Mesquite ISD; 3. Parent's divorce; 4. The employee of Mesquite ISD becomes entitled to Medicare; or 5. You cease to be a "dependent child" under the terms of the health, dental, and/or vision plan.

4 Employee/Qualified Beneficiary Notification Responsibilities Under group health, dental, and/or vision plan rules and COBRA law, the employee, spouse, or other family member has the responsibility to notify Mesquite ISD of a divorce or a child losing dependent status under the plan. This notification must be made within 31 days from whichever date is later, the date of the event or the date on which health, dental, and/or vision plan coverage would be lost under the terms of the insurance contract because of the event. If a divorce occurs or a dependent ceases to be an eligible dependent under the terms of the plan, return the enclosed COBRA Qualifying Event Notification Form by first class mail to the address stated on the form. If this notification is not completed according to the above procedures and within the required 31-day notification period, then rights to continuation coverage will be forfeited. Continuation coverage rights under COBRA are contained in the online Benefits Booklet from the Plan Administrator ( and in the MISD employee benefits booklet ( Department). Election Period And Coverage - Once the plan administrator learns from you that a qualifying event has occurred, the plan administrator will notify covered individuals (also known as qualified beneficiaries) of their rights to elect continuation coverage. Each qualified beneficiary has independent election rights and will have 60 days to elect continuation coverage. The 60-day election window is measured from the later of the date health, dental, and/or vision plan coverage is lost due to the event or from the date of notification. This is the maximum period allowed to elect continuation coverage as the plan does not provide an extension of the election period beyond what is required by law. If a qualified beneficiary does not elect continuation coverage within this election period, then rights to continue health, dental, and/or vision insurance will end and they cease to be a qualified beneficiary. If a qualified beneficiary elects continuation coverage, they will be required to pay the entire cost for the health, dental, and/or vision insurance, plus a 2% administration fee. Mesquite ISD is required to provide the qualified beneficiary with coverage that is identical to the coverage provided under the plan to similarly situated noncobra participants and/or covered dependents. Should coverage change or be modified for noncobra participants, then the change and/or modification will be made to your coverage as well. Length of Continuation Coverage - 18 Months. If the event causing the loss of coverage is a termination of employment (other than for reasons of gross misconduct) or a reduction in work hours, then each qualified beneficiary will have the opportunity to continue coverage for 18 months from the date of the qualifying event. Social Security Disability - The 18 months of continuation coverage can be extended for an additional 11 months of coverage, to a maximum of 29 months, for all qualified beneficiaries if the Social Security Administration determines a qualified beneficiary was disabled according to Title II or XVI of the Social Security Act on the date of the qualifying event or at any time during the first 60 days of continuation coverage. In the case of a newborn or adopted child that is added to a covered employee's COBRA coverage, then the first 60 days of continuation coverage for the newborn or adopted child is measured from the date of the birth or the date of the adoption. It is the qualified beneficiary's responsibility to obtain this disability determination from the Social Security Administration and provide a copy of the determination to Mesquite ISD within 60 days after the date of determination and before the original 18 months expire.

5 Secondary Qualifying Event An 18-month extension of coverage will be available to spouses and dependent children who elect continuation coverage if a second qualifying event occurs during the first 18 months of continuation coverage. The maximum amount of 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, the covered employee s becoming entitled to Medicare benefits (under Part A, Part B, or both), 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. You must notify the Plan within 60 days of the later of (1) the date on which the qualifying event occurs; or (2) the date coverage would have been lost as a result of the qualifying event. Length of Continuation Coverage - 36 Months. If the original event causing the loss of coverage was the death of the employee, divorce, Medicare entitlement, or a dependent child ceasing to be an eligible dependent, then each dependent qualified beneficiary will have the opportunity to continue coverage for a maximum of 36 months from the date of the qualifying event. Premiums - A qualified beneficiary will have to pay all of the applicable premium plus a 2% administration charge for continuation coverage. These premiums will be adjusted during the continuation period if the applicable premium amount changes. In addition, if continuation coverage is extended from 18 months to 29 months due to a Social Security disability, Mesquite ISD can charge up to 150% of the applicable premium during the extended coverage period. Qualified beneficiaries will be allowed to pay on a monthly basis. In addition there will be a maximum grace period of (30) days for the regularly scheduled monthly premiums. Mesquite ISD does not provide a conversion plan at the end of your coverage. Cancellation Of Continuation Coverage - The law provides that COBRA continuation coverage will end prior to the maximum continuation period for any of the following reasons: 1. Mesquite ISD ceases to provide any group health, dental, and/or vision plan to any of its employees; 2. Any required premium for continuation coverage is not paid in a timely manner; 3. A qualified beneficiary first becomes, after the date of COBRA election, covered under another group health, dental, and/or vision plan that does not contain any exclusion or limitation with respect to any preexisting condition of such beneficiary other than such an exclusion or limitation which does not apply to or is satisfied by such beneficiary by reason of the Health Insurance Portability and Accountability Act of 1996; 4. A qualified beneficiary first becomes, after the date of COBRA election, entitled to Medicare; 5. A qualified beneficiary extended continuation coverage to 29 months due to a Social Security disability and a final determination has been made that the qualified beneficiary is no longer disabled; 6. A qualified beneficiary notifies Mesquite ISD they wish to cancel COBRA continuation coverage. 7. For cause, on the same basis that the plan terminates the coverage of similarly situated noncobra participants.

6 Notification Of Address Change -To ensure all covered individuals receive information properly and efficiently, it is important you notify Mesquite ISD of any address change as soon as possible. Failure on your part to do so will result in delayed notifications or a loss of continuation coverage options. Complete a Cobra Address Notification Form, sample located at the end of this notice. Any Questions? - Remember, this notice is simply a summary of your potential future options. Should an actual qualifying event occur and it is determined that you are eligible for continuation of coverage, you will be notified of all your actual rights at that time. If any covered individual does not understand any part of this summary notice or has questions regarding the information or your obligations, please contact the Mesquite ISD Benefits Office at COBRA ADMINISTRATION CONTACT INFORMATION Health continuation of coverage: If you have any questions concerning your rights to health continuation of coverage, you should contact WellSystems at COBRA@wellsystems.com, (Monday Friday from 7 a.m. to 4 p.m. Central Standard Time) or WellSystems TRS Team, PO Box 1390, Brandon, FL If you want to talk to someone about the insurance or prescription benefits or the Aetna or Caremark network, please call Aetna also has complete information available on its website at For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the U.S. Department of Labor s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA Web site at (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA s Web site.) Dental continuation of coverage: If you have questions concerning your rights to dental continuation of coverage, you should contact Mesquite ISD Benefits Office at or write to Mesquite ISD Benefits Office, 3819 Towne Crossing, Mesquite, TX Vision continuation of coverage: If you have questions concerning your rights to vision continuation of coverage, you should contact Mesquite ISD Benefits Office at or write to Mesquite ISD Benefits Office, 3819 Towne Crossing, Mesquite, TX

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8 COBRA QUALIFYING EVENT NOTIFICATION FORM ATTENTION COVERED EMPLOYEE AND/OR COVERED SPOUSE AND DEPENDENT: This form is to be completed by a covered employee, spouse, or dependent to report certain events to Mesquite ISD's Benefits Office as required under provisions of the federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). Failure to complete and submit this form in a timely manner will result in a loss of health, dental, and/or vision insurance continuation rights that are available under COBRA. Should you have any questions as to this form s purpose or how to complete the form, contact the Mesquite ISD Benefits Office at INSTRUCTIONS 1. If a COBRA qualifying event occurs (divorce, dependent ceases to be a dependent, SSA disability), completely fill out this form and submit it to the Benefits Office. 2. Attach required documentation, and keep a copy of form and documentation for your records. 3. Mail all information to Mesquite ISD Benefits Office (address below). Name of Company: Name of Covered Employee: Name of Reportee: Relationship to Employee: PLEASE CHECK ONE Divorce Date of Event: (Attach a copy of the signed/certified copy of Divorce Decree. The notice must be mailed (postmarked) to the Mesquite ISD Benefits Office within 60 days of the date of the event or from the plan loss coverage date, whichever is later.) Child Ceasing To Be A Dependent Date of Event: Reason: (This notice must be mailed (postmarked) to the Mesquite ISD Benefits Office within 60 days of the date of the event or from the plan loss of coverage date, whichever is later.) Social Security Disability Date of SSA Disability: (If the Social Security Administration determines that you are no longer disabled, you must notify the Benefits Office within 30 days of the SSA determination. Attach a copy of the SSA determination.) CURRENT MAILING ADDRESS of Qualified Beneficiary Street Address: City, State, Zip: Telephone: Signature of Reportee MAIL COMPLETED FORM TO: Mesquite ISD Benefits Office 3819 Towne Crossing Mesquite, TX Date

9 To the covered employee and plan participants: COBRA ADDRESS NOTIFICATION FORM It is important that you keep the Mesquite ISD Benefits Office informed of your current address so that all covered individuals under the plan receive timely information about plan benefits and group plan continuation coverage rights. So this form is to be used by you for two purposes: SECTION 1: NOTIFCIATION OF ADDRESS CHANGE Plan information is sent to the address you have provided to the Mesquite ISD Benefits Office. Should you move, please complete Section 1 and send the form to the address listed below. SECTION 2: NOTIFICATION OF COVERED DEPENDENT ADDRESS When coverage under the group plan begins, or should you experience a COBRA qualifying event in the future, the plan administrator is required to send you information concerning your plan continuation rights. If, upon receiving such a notice, you have a covered dependent whose legal residence is not yours (dependent child covered by court order, living with an ex-spouse, etc.), you are required to provide the plan with a current address so an initial or election notice can be sent to them as well. Please complete Section 2 for this purpose and send to the address listed below. You should make a copy of this form prior to mailing and you should call the Mesquite ISD Benefits Office within 10 days to ensure the information has been received. Should you have any questions, please call Thank you for your assistance. SECTION 1: NOTIFCIATION OF ADDRESS CHANGE Name of Employee: New Address: City, State, Zip: SECTION 2: NOTIFICATION OF COVERED DEPENDENT ADDRESS 1. Name of covered dependent: Name of guardian, ex-spouse, etc.: Street address: City, State, Zip: 2. Name of covered dependent: Name of guardian, ex-spouse, etc.: Street address: City, State, Zip: Signature of Reportee Date MAIL COMPLETED FORM TO: Mesquite ISD Benefits Office 3819 Towne Crossing Mesquite, TX 75150