INITIAL NOTICE OF CONTINUATION COVERAGE UNDER THE HEALTH PLAN OF KINDER MORGAN. Very Important Notice

Size: px
Start display at page:

Download "INITIAL NOTICE OF CONTINUATION COVERAGE UNDER THE HEALTH PLAN OF KINDER MORGAN. Very Important Notice"

Transcription

1 INITIAL NOTICE OF CONTINUATION COVERAGE UNDER THE HEALTH PLAN OF KINDER MORGAN Very Important Notice January 1, 2010 Dear Employee (and Spouse, if applicable): IT IS IMPORTANT THAT ALL COVERED INDIVIDUALS (EMPLOYEE, SPOUSE AND DEPENDENT CHILDREN) TAKE THE TIME TO READ THIS NOTICE CAREFULLY AND BE FAMILIAR WITH ITS CONTENTS. You are receiving this notice because you have recently become eligible for coverage by the Kinder Morgan Health & Welfare Benefit Plan (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage by the Plan. The right to COBRA continuation coverage was created by a federal law, Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage may become available to you and to other members of your family who are covered by the Plan when you would otherwise lose your group health coverage. 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. This notice gives only a summary of your COBRA continuation coverage rights. For more information about your rights and obligations by the Plan and under federal law, you should either review the Plan's Summary Plan Description or get a copy of the Plan Document from the Plan Administrator. The Plan Administrator is: Director, Benefits Kinder Morgan 500 Dallas, Suite 1000 Houston, TX (713) COBRA Continuation Coverage 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 the notice. COBRA continuation coverage must be offered to each person who is a qualified beneficiary. A qualified beneficiary is someone who will lose coverage by the Plan because of a qualifying event. Depending on the type of qualifying event, employees, spouses of employees, and dependent children of employees may be qualified beneficiaries. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

2 If you are an employee, you will become a qualified beneficiary if you will lose your coverage by the Plan because either one of the following qualifying events happens: 1. Your hours of employment are reduced and you no longer meet Plan eligibility requirements, or 2. Your employment ends for any reason other than your gross misconduct. If you are the spouse of an employee, you will become a qualified beneficiary if you will lose your coverage by the Plan because any of the following qualifying events happens: 1. Your spouse dies; 2. Your spouse's hours of employment are reduced and he or she no longer meets Plan eligibility requirements; 3. Your spouse's employment ends for any reason other than his or her gross misconduct; 4. Your spouse becomes enrolled in Medicare (Part A, Part B, or both); or 5. You become divorced or legally separated from your spouse. Your dependent children will become qualified beneficiaries if they will lose coverage by the Plan because any of the following qualifying events happens: 1. The parent-employee dies; 2. The parent-employee's hours of employment are reduced and he or she no longer meets Plan eligibility requirements; 3. The parent-employee's employment ends for any reason other than his or her gross misconduct; 4. The parent-employee becomes enrolled in Medicare (Part A, Part B, or both); 5. The parents become divorced or legally separated; or 6. The child stops being eligible for coverage by the Plan as a dependent child. Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code may be a qualifying event. If a proceeding in bankruptcy is filed with respect to Kinder Morgan and that bankruptcy results in the loss of coverage of any retired employee covered by the Plan, the retired employee is a qualified beneficiary with respect to the bankruptcy. The retired employee's spouse, surviving spouse, and dependent children will also be qualified beneficiaries if bankruptcy results in the loss of their coverage by the Plan. The Plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the employee, or enrollment of the employee in Medicare (Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event. In addition, if the Plan provides retiree health coverage, then commencement of a proceeding in a bankruptcy with respect to the employer is also a qualifying event where the employer must notify the Plan Administrator of the qualifying event. You must notify the Plan Administrator of other qualifying events (divorce or legal separation of the employee and spouse or a dependent child's losing eligibility for coverage as a dependent child). The Plan requires you to notify the Plan Administrator, in writing, within 60 days after the qualifying event occurs to be eligible to receive COBRA continuation coverage. This notification may be made by

3 completing an Employee Benefits Change Form and providing supporting documentation as noted on this form. Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. COBRA continuation coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would otherwise have been lost for each qualified beneficiary who elects COBRA continuation coverage, depending on the nature of the Plan. COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, enrollment of the employee in Medicare (Part A, Part B, or both), your divorce or legal separation, or a dependent child losing eligibility as a dependent child, COBRA continuation coverage lasts for up to 36 months. For what period of time may coverage be continued? 18 Months of Continued Coverage 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, each qualified beneficiary will have the opportunity to continue coverage for up to 18 months from the date of the qualifying event. CALIFORNIA RESIDENTS ONLY As required by California Assembly Bill (AB) 1401, continuation of health care coverage is extended to all Cal-COBRA eligible individuals for up to 36 months effective January 1, 2003, regardless of the beneficiary s qualifying event. 29 Months of Continued Coverage Continuation of coverage may be extended up to 29 months if any qualified beneficiary is disabled within the first 60 days of COBRA coverage in accordance with the provisions of the Social Security Act. The extension to up to 29 months is available only if the qualified beneficiary provides notice of the disability determination within the 18-month period after the qualified event. The notice must be given within 60 days of the date of the disability determination to the company. The company must also be notified of any final determination that the qualified beneficiary is no longer disabled. 36 Months of Continued Coverage If the event causing the loss of coverage was the death of the employee, divorce, legal separation, or a dependent child ceasing to be a dependent child under the Health Plan of the company, each beneficiary will have the opportunity to continue coverage up to 36 months from the date of the qualifying event. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event while receiving COBRA continuation coverage, the spouse and dependent children in your family may be eligible for additional months of COBRA continuation coverage, up to a maximum of 36 months. This extension is available to the spouse and dependent children if the former employee dies, enrolls in Medicare (Part A, Part B, or both), or becomes divorced or legally separated. The extension is also available to a dependent child when that child stops being eligible by the Plan as a dependent child. In all of these cases, you must make sure that the Plan Administrator is notified of the second qualifying event within 60 days of the second qualifying event. Under What Circumstances May Continuation Coverage Be Terminated? The law provides that if elected and paid, continuation coverage may end prior to the maximum continuation period for any of the following reasons: 1. The company, ceases to provide any group health plan to any of its employees; 2. Any required premium for continuation coverage is not paid in a timely manner;

4 3. A qualified beneficiary becomes covered under another group health plan, unless there are pre-existing conditions not covered by that plan. If the qualified beneficiary becomes covered by another group health plan and that plan contains a pre-existing condition limitation that affects coverage, COBRA continuation coverage cannot be terminated. However, if the other plan's pre-existing condition rule does not apply by reason of HIPAA's restrictions on pre-existing conditions, COBRA coverage may be terminated; 4. A qualified beneficiary becomes 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; or 6. A qualified beneficiary notifies the company that they wish to cancel continuation coverage. When Must A Decision To Continue Be Made? A covered employee, spouse or dependent has 60 days from the date coverage would otherwise terminate or the date the election notice is sent to you, whichever date is later. How Are Premium Payments Made? For the first premium payment you have 45 days from the date you elect to continue coverage to pay the retroactive premium. Thereafter your premiums are payable on a monthly basis. There is a grace period of 30 days for the regularly scheduled monthly premiums. If your payment is not received on a timely basis, your insurance will be canceled. Important Notifications Required By An Employee, Spouse And Dependent The employee, spouse or other family member has the responsibility to inform the company, in writing, of a divorce, legal separation, or a child losing dependent status under the Health Plan of the company. This notification must be made within 60 days from whichever date is later, the date of the event or the date on which coverage would be lost because of the event. Please check with the Human Resources/Benefits Department for procedures to follow in making this notification. If this notification is not completed in a timely manner, then rights to continuation coverage may be forfeited. Eligibility Premiums And Potential Conversion Rights A qualified beneficiary does not have to show that they are insurable to elect continuation coverage. The company, however, reserves the right to verify eligibility status and terminate continuation coverage retroactively if you are determined to be ineligible or if there has been a material misrepresentation of the facts. A qualified beneficiary may have to pay all of the applicable premium plus a 2% administration charge for continuation coverage. These premiums may be adjusted in the future 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, the company can charge up to 150% of the applicable premium during the extended coverage period. There is a grace period of 30 days for the regularly scheduled monthly premiums. If a plan contains a right to convert to an individual policy, that benefit will also be made available to qualified beneficiaries under COBRA. When the COBRA continuation coverage expires, the qualified beneficiary will be provided with the option of enrolling in the conversion health plan normally available under the plan. However, if the qualified beneficiary has for some reason ceased coverage before the applicable 18, 29, or 36 month period terminates, this conversion right will not be offered. Keep Your Plan Informed Of Address Changes To protect your family's rights, you should keep the Plan Administrator informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan Administrator. Questions? If you have questions about your COBRA continuation coverage, contact the Kinder Morgan Benefit Department at (800) , prompt 1, ext or contact the nearest Regional or District Office of the U.S Department of Labor's Employee Benefits Security Administration (EBSA). Addresses and phone numbers of Regional and District EBSA Offices are available on EBSA's website at

5 January 1, 2010 The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes some provisions that may affect decisions you make about your participation in the Group Health Plan under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). These provisions are as follows: 1. Under COBRA, if the qualifying event is a termination or reduction in hours of employment, affected qualified beneficiaries are entitled to continue coverage for up to 18 months after the qualifying event, subject to various requirements. Prior to HIPAA, this 18-month period could be extended for up to 11 months (for a total COBRA coverage period of up to 29 months from the initial qualifying event) if an individual was determined by the Social Security Administration, under the Social Security Act, to have been disabled at the time of the qualifying event and if the Plan Administrator was notified of that disability determination within 60 days of the determination and before the end of the original 18-month period. Under HIPAA, if a qualified beneficiary is determined by the Social Security Administration to be disabled under the Social Security Act at any time during the first 60 days of COBRA coverage, the 11-month extension is available to all individuals who are qualified beneficiaries due to the termination or reduction in hours of employment. The disabled individual may be a covered employee or any other qualified beneficiary. However, to be eligible for the 11-month extension, affected individuals must still comply with the notification requirements in a timely fashion. 2. A child that is born to or placed for adoption with the covered employee during a period of COBRA coverage will be eligible to become a qualified beneficiary. In accordance with the terms of the employer's group health plan(s) and the requirements of Federal law, these qualified beneficiaries may be added to COBRA coverage upon proper notification to the Plan Administrator of the birth or adoption. 3. If you were covered by a group health plan(s) prior to your employment with Kinder Morgan, your previous employer s insurance carrier should have provided you with a Certificate of Creditable Coverage, a form required by the HIPAA law that describes the health coverage you and your dependents, if any, have or had, and the dates you were covered. IF YOU HAVE NOT RECEIVED A CERTIFICATE OF CREDITABLE COVERAGE AND ARE ENTITLED TO ONE, PLEASE CONTACT YOUR FORMER EMPLOYER. Once you deliver the Certificate of Creditable Coverage to us, you are exempt from any pre-existing condition exclusions in our group health plan(s), provided you had twelve months of creditable coverage (eighteen months if a late enrollment) and have not had more than a sixty-three day gap in coverage. 4. HIPAA restricts the extent to which group health plans may impose pre-existing condition limitations. 5. Under COBRA, your right to continuation coverage terminates if you become covered by another employer's group health plan that does not limit or exclude coverage for your pre-existing conditions. If you become covered by another group health plan and that plan contains a pre-existing condition limitation that affects you, your COBRA continuation coverage cannot be immediately terminated. However, if the other plan's pre-existing condition rule does not apply to you by reason of HIPAA's restrictions on pre-existing condition clauses, the employer's group health plan(s) may terminate your COBRA coverage.

6 Special Enrollment for Loss of Other Coverage If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents other coverage). However, you must request enrollment within 30 days after you or your dependents other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. The ( CHIP ) Children's Health Insurance Program ("CHIP") Reauthorization Act of 2009 (the "Act") Effective April 1, 2009, if you or your eligible dependents; (1) lose coverage under your respective state Medicaid or child health plan (CHIP); or (2) become eligible for premium assistance under the Medicaid or child health plan (CHIP), you or your eligible dependents will be eligible to enroll in the Kinder Morgan group health and/or welfare plans. You must request coverage no later than sixty 60 days after the new qualifying event(s). Michelle s Law Continuation of Coverage Effective January 1, 2010, Michelle s law (Federal HR 2851) extends coverage to a dependent who suffers from a serious illness or injury which results in the dependent taking a medically necessary leave of absence from a post secondary institution, (College) or changing to a part-time student status. Michelle s law applies to a dependent child who was enrolled on the Plan on the basis of being a student immediately before the first day of medically necessary leave of absence. Coverage will continue until the earlier of: one year after the first day of medically necessary leave; or the date on which coverage would otherwise terminate under the Plan (Age 25). The period of coverage begins on the date the written certification by the student s physician, determines the illness or injury began which prevents the dependent child from attending school or change to less than fulltime status. Physician verification of serious illness or injury Verification that the dependent child is suffering from a serious illness or injury and that the leave of absence is medically necessary must be supported by a clinical certification of need from a physician licensed to practice medicine in all its branches. To request special enrollment or obtain more information or you have any questions about COBRA, or if you have changed marital status, or you or your spouse have changed addresses or, for any applicable forms please contact the Kinder Morgan Benefit Department at (800) , prompt 1, ext Sincerely, Kinder Morgan Revised 10/1/2009

General Notice Of COBRA Continuation Coverage Rights. ** Continuation Coverage Rights Under COBRA**

General Notice Of COBRA Continuation Coverage Rights. ** Continuation Coverage Rights Under COBRA** General Notice Of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Dear Qualified Beneficiary: CONTINUATION COVERAGE RIGHTS UNDER COBRA Introduction You and your covered

More information

TO: Employee/Spouse and family, Address, City, State, Zip Code FROM: [Employer Name] DATE: [Date] RE: CONTINUATION COVERAGE RIGHTS UNDER COBRA

TO: Employee/Spouse and family, Address, City, State, Zip Code FROM: [Employer Name] DATE: [Date] RE: CONTINUATION COVERAGE RIGHTS UNDER COBRA SAMPLE FORM: INITIAL COBRA NOTICE This is the Notice required to be given to: (a) each participant when he or she first becomes covered by the plan; and (b) each spouse of a participant when that spouse

More information

GENERAL NOTICE OF CONTINUATION COVERAGE RIGHTS UNDER COBRA

GENERAL NOTICE OF CONTINUATION COVERAGE RIGHTS UNDER COBRA GENERAL NOTICE OF CONTINUATION COVERAGE RIGHTS UNDER COBRA You are receiving this notice because you recently became covered under American Airlines Group Health Plan (the Plan). This notice contains important

More information

GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS ** CONTINUATION COVERAGE RIGHTS UNDER COBRA**

GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS ** CONTINUATION COVERAGE RIGHTS UNDER COBRA** GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS ** CONTINUATION COVERAGE RIGHTS UNDER COBRA** Date of Notice: January 15, 2015 TO: FROM: Employee, Spouse and/or Dependent Child(ren) Hal Smith Restaurant

More information

Kern County HR County Administrative Office

Kern County HR County Administrative Office Kern County HR County Administrative Office 1115 Truxtun Avenue, 1st Floor, Bakersfield, CA 93301 Telephone (661) 868-3182 Fax (661) 868-3110 Ryan Alsop County Administrative Officer Devin Brown Chief

More information

Initial COBRA Notification Continuation Rights Under COBRA

Initial COBRA Notification Continuation Rights Under COBRA Introduction Initial COBRA Notification Continuation Rights Under COBRA Below is the Group Health Continuation under COBRA - notice. The purpose of this initial notice is to acquaint you with the COBRA

More information

Notice of COBRA Continuation Coverage Rights

Notice of COBRA Continuation Coverage Rights Notice of COBRA Continuation Coverage Rights Introduction This notice contains important information about your right to COBRA continuation coverage. This notice generally explains COBRA continuation coverage,

More information

Continuing Coverage under COBRA

Continuing Coverage under COBRA Continuing Coverage under COBRA The right to purchase a temporary extension of health coverage was created by the Consolidated Omnibus Budget Reconciliation Act of 1985, a federal law commonly known as

More information

Page 1 -- CLC01. WageWorks, Inc. P.O. Box Dallas, TX Date: Form: Doc ID: Account #:

Page 1 -- CLC01. WageWorks, Inc. P.O. Box Dallas, TX Date: Form: Doc ID: Account #: Re: Important General Notice of COBRA Continuation Coverage Rights Johns Hopkins University - 32829 00870140103701 Introduction This is for informational purposes only. You are receiving this notice because

More information

NO ACTION REQUIRED. This is for informational purposes only.

NO ACTION REQUIRED. This is for informational purposes only. NO ACTION REQUIRED. This is for informational purposes only. IMPORTANT GENERAL NOTICE OF COBRA CONTINUATION OF GROUP HEALTH COVERAGE RIGHTS INTRODUCTION You are receiving this notice because you have recently

More information

General Notice of COBRA Continuation Coverage Rights. ** Continuation Coverage Rights Under COBRA**

General Notice of COBRA Continuation Coverage Rights. ** Continuation Coverage Rights Under COBRA** General Notice of COBRA Continuation Coverage Rights ** Continuation Coverage Rights Under COBRA** Introduction You re getting this notice because you recently gained coverage under a group health plan

More information

COBRA GENERAL NOTICE of the SOUTHERN CALIFORNIA PUBLIC SAFETY RETIREE MEDICAL TRUST

COBRA GENERAL NOTICE of the SOUTHERN CALIFORNIA PUBLIC SAFETY RETIREE MEDICAL TRUST NOTICE G COBRA GENERAL NOTICE of the SOUTHERN CALIFORNIA PUBLIC SAFETY RETIREE MEDICAL TRUST > THIS COBRA INFORMATION WILL INFORM YOU OF YOUR RIGHTS AND OBLIGATIONS UNDER

More information

1. Employee/parent becomes enrolled in Medicare 2. Dependent child ceases to be a dependent under the terms of the group health plan

1. Employee/parent becomes enrolled in Medicare 2. Dependent child ceases to be a dependent under the terms of the group health plan GENERAL COBRA NOTICE Introduction The following information is intended to inform you, in a summary fashion, of your rights and obligations under the continuation of coverage provisions of Minnesota and

More information

Model COBRA Continuation Coverage General Notice Instructions

Model COBRA Continuation Coverage General Notice Instructions Model COBRA Continuation Coverage General Notice Instructions The Department of Labor has developed a model Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) continuation coverage general

More information

COBRA ELECTION NOTICE

COBRA ELECTION NOTICE COBRA ELECTION NOTICE Date of Notice: DATE NAME ADDRESS CITY STATE ZIP NOTICE OF RIGHT TO ELECT COBRA CONTINUATION COVERAGE This notice contains important information about your right to continue your

More information

New Health Insurance Marketplace Coverage Options and Your Health Coverage

New Health Insurance Marketplace Coverage Options and Your Health Coverage New Health Insurance Marketplace Coverage Options and Your Health Coverage Form Approved OMB No. PART A: General Information When key parts of the health care law take effect in 2014, there will be a new

More information

Your Health Care Benefit Program

Your Health Care Benefit Program Your Health Care Benefit Program HMO ILLINOIS A Blue Cross HMO a product of Blue Cross and Blue Shield of Illinois A message from BLUE CROSS AND BLUE SHIELD Your Group has entered into an agreement with

More information

COBRA Continuation Coverage

COBRA Continuation Coverage COBRA Continuation Coverage The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), is a federal law that requires plans to offer a temporary extension of benefits to employees and eligible

More information

COBRA INITIAL/GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS **CONTINUATION COVERAGE RIGHTS UNDER COBRA** C&A Industries, Inc.

COBRA INITIAL/GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS **CONTINUATION COVERAGE RIGHTS UNDER COBRA** C&A Industries, Inc. Initial Notice of COBRA Rights COBRA INITIAL/GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS Introduction **CONTINUATION COVERAGE RIGHTS UNDER COBRA** C&A Industries, Inc. C&A Industires, Inc. Benefits

More information

General Notice. COBRA Continuation Coverage Notice (and Addendum)

General Notice. COBRA Continuation Coverage Notice (and Addendum) University Human Resources Benefits Office 3810 Beardshear Hall Ames, Iowa 50011-2033 515-294-4800 / 1-877-477-7485 Phone 515-294-8226 FAX General Notice And COBRA Continuation Coverage Notice (and Addendum)

More information

COBRA GENERAL NOTICE of the BURBANK EMPLOYEES RETIREE MEDICAL TRUST

COBRA GENERAL NOTICE of the BURBANK EMPLOYEES RETIREE MEDICAL TRUST COBRA GENERAL NOTICE of the > THIS COBRA INFORMATION WILL INFORM YOU OF YOUR RIGHTS AND OBLIGATIONS UNDER COBRA. YOU AND YOUR SPOUSE SHOULD TAKE THE TIME TO READ THIS CAREFULLY.

More information

I. Qualifying Events/Qualified Beneficiaries. Those individuals eligible for COBRA continuation coverage as Qualified Beneficiaries are as follows:

I. Qualifying Events/Qualified Beneficiaries. Those individuals eligible for COBRA continuation coverage as Qualified Beneficiaries are as follows: The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires that your group health plan (the Plan) allow qualified persons (as defined below) to continue group health coverage after it

More information

General Notice of COBRA Continuation Coverage Rights

General Notice of COBRA Continuation Coverage Rights General Notice of COBRA Continuation Coverage Rights You are receiving this information as a participant in the group medical, dental and/or vision plans provided by Toys R Us, Inc. This notice contains

More information

Frequently Asked Questions - COBRA and How to Continue Your Healthcare Coverage

Frequently Asked Questions - COBRA and How to Continue Your Healthcare Coverage Frequently Asked Questions - COBRA and How to Continue Your Healthcare Coverage Many people have health insurance through their employer's group plan. When they no longer qualify for coverage through this

More information

COBRA GENERAL NOTICE MAILING

COBRA GENERAL NOTICE MAILING COBRA GENERAL NOTICE MAILING Date: To: From: Findlay City Schools 1100 Broad Ave Findlay, OH 45840 Introduction to COBRA: This notice is intended to provide information about your rights and responsibilities

More information

Generally, your coverage as a Retiree ends when the first of the following events occurs:

Generally, your coverage as a Retiree ends when the first of the following events occurs: Self-Payments and Continuing Eligibility You will continue to be eligible for Retiree Benefits provided you make the required selfpayments. The Trustees determine the amount of self-payments and the amount

More information

Model COBRA Continuation Coverage Election Notice (For use by single-employer group health plans)

Model COBRA Continuation Coverage Election Notice (For use by single-employer group health plans) Model COBRA Continuation Coverage Election Notice (For use by single-employer group health plans) [Enter date of notice] Dear : [Identify the qualified beneficiary(ies), by name or status] This notice

More information

GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS ** CONTINUATION COVERAGE RIGHTS UNDER COBRA**

GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS ** CONTINUATION COVERAGE RIGHTS UNDER COBRA** GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS ** CONTINUATION COVERAGE RIGHTS UNDER COBRA** From: RITALKA, INC. 121 North 1 st Street Montevideo, MN 56265 320-269-3227 You re getting this notice

More information

EASTERN SHORE COMMUNITY SERVICES BOARD CAFETERIA PLAN SUMMARY PLAN DESCRIPTION

EASTERN SHORE COMMUNITY SERVICES BOARD CAFETERIA PLAN SUMMARY PLAN DESCRIPTION EASTERN SHORE COMMUNITY SERVICES BOARD CAFETERIA PLAN SUMMARY PLAN DESCRIPTION TABLE OF CONTENTS I ELIGIBILITY 1. When can I become a participant in the Plan?... 1 2. What are the eligibility requirements

More information

Notification of Rights to Continue University of Rochester Health Care Coverage under COBRA

Notification of Rights to Continue University of Rochester Health Care Coverage under COBRA Notification of Rights to Continue University of Rochester Health Care Coverage under COBRA January 2018 Introduction You are receiving this notice because you have recently become covered under one or

More information

General Notice of COBRA Continuation Coverage Rights. **Continuation Coverage Rights Under COBRA**

General Notice of COBRA Continuation Coverage Rights. **Continuation Coverage Rights Under COBRA** General Notice of COBRA Continuation Coverage Rights **Continuation Coverage Rights Under COBRA** Introduction You are getting this notice because you recently gained coverage under The Vanguard Group,

More information

CONEXIS P.O. Box Dallas, TX

CONEXIS P.O. Box Dallas, TX CONEXIS P.O. Box 223684 Dallas, TX 75222-3684 Date: 5/24/2016 Form: CLC02-CXTEN Doc ID: Account #: To Participant Name: Employer: UNIVERSITY OF AKRON (THE) Election Deadline: 7/26/2016 Qualifying Event:

More information

Initial Notice Form COBRA Notice Upon Enrollment in a Group Health Plan

Initial Notice Form COBRA Notice Upon Enrollment in a Group Health Plan Initial Notice Form COBRA Notice Upon Enrollment in a Group Health Plan VERY IMPORTANT NOTICE If a qualifying event occurs that causes you or your spouse or dependent children to lose coverage under group

More information

Your Rights Under COBRA VERY IMPORTANT NOTICE

Your Rights Under COBRA VERY IMPORTANT NOTICE Gordon L. Barger Senior Director Benefits Administration & Services Cornell University 395 Pine Tree Rd., EH OB, Ithaca, NY 14850-2801 t. 607.255.3936 f. 607.255.6873 e. benefits@cornell.edu www.hr.cornell.edu

More information

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

Cobra Information. Health Insurance Provider Name: WellSystems Phone Number: Cobra Information Clipart of: Words to be continued Health Insurance Provider Name: WellSystems Phone Number: 844-752-5146 Dental & Vision Insurance Provider Name: MISD-Benefits Phone Number: 972-882-7359

More information

Your Health Care Benefit Program

Your Health Care Benefit Program Your Health Care Benefit Program BLUE ADVANTAGE HMO A Blue Cross HMO a product of Blue Cross and Blue Shield of Illinois HMO GROUP CERTIFICATE RIDER This Certificate, to which this Rider is attached to

More information

Model General Notice of COBRA Continuation Coverage Rights

Model General Notice of COBRA Continuation Coverage Rights Model General Notice of COBRA Continuation Coverage Rights Introduction You re getting this notice because you recently gained coverage under a group health plan (the Plan). This notice has important information

More information

SURA/JEFFERSON SCIENCE ASSOCIATES, LLC

SURA/JEFFERSON SCIENCE ASSOCIATES, LLC SURA/JEFFERSON SCIENCE ASSOCIATES, LLC COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN Summary Plan Description Amended and Restated Effective April 1, 2011 YOUR SUMMARY PLAN DESCRIPTION This document is

More information

Included with your Employee Handbook COBRA NOTICE

Included with your Employee Handbook COBRA NOTICE Included with your Employee Handbook COBRA NOTICE This COBRA Notice is being sent to Employees and Beneficiaries Participating in Philadelphia University s Health Plan. Please be informed that this notice

More information

**CONTINUATION COVERAGE RIGHTS UNDER COBRA**

**CONTINUATION COVERAGE RIGHTS UNDER COBRA** **CONTINUATION COVERAGE RIGHTS UNDER COBRA** Federal law requires certain employers sponsoring group health plan coverage to offer their employees (and his or her enrolled family members) the opportunity

More information

State and School Employees Health Insurance Plan CONTINUATION COVERAGE ELECTION NOTICE

State and School Employees Health Insurance Plan CONTINUATION COVERAGE ELECTION NOTICE State and School Employees Health Insurance Plan CONTINUATION COVERAGE ELECTION NOTICE Health5 (Rev. 12/04) To: _ Name of Employee or Qualified Beneficiary(ies) Date Notified This notice contains important

More information

Your Health Care Benefit Program

Your Health Care Benefit Program Your Health Care Benefit Program BLUE ADVANTAGE HMO A Blue Cross HMO a product of Blue Cross and Blue Shield of Illinois A message from BLUE CROSS AND BLUE SHIELD Your Group has entered into an agreement

More information

-DEPARTMENT LETTERHEAD- SAMPLE INITIAL GENERAL COBRA NOTICE COVER PAGE

-DEPARTMENT LETTERHEAD- SAMPLE INITIAL GENERAL COBRA NOTICE COVER PAGE -DEPARTMENT LETTERHEAD- SAMPLE INITIAL GENERAL COBRA NOTICE COVER PAGE TO: FROM: DATE: Sam and Lisa Johnson and all covered dependents (if any) (Current Address) Department Representative Name Department

More information

Medical: Premium Quality Value HSA MEC NONE. Dental: Premium Quality NONE

Medical: Premium Quality Value HSA MEC NONE. Dental: Premium Quality NONE ENROLLMENT / CHANGE FORM Addition Change Termination Reason: Effective Date If change or termination, complete only Employee s Name, Social Security Number, and the Change details. Termination date includes

More information

Sample COBRA Notice. ABC Company c/o The COBRA Administrator s Name 1234 South St City, State and Zip 06/10/2008

Sample COBRA Notice. ABC Company c/o The COBRA Administrator s Name 1234 South St City, State and Zip 06/10/2008 ABC Company c/o The COBRA Administrator s Name 06/10/2008 PQB Name: Spouse Name: Street Address Street Address This notice contains important information about your right to continue your health care coverage

More information

Compliance Guide. Presented By:

Compliance Guide. Presented By: 2016-2017 Compliance Guide Presented By: 1 Introduction This booklet contains mandatory annual notices regarding your health and welfare benefit plans through Washington Odd Fellows Home for the plan year

More information

PLAN AMENDMENT FOR LINCOLNWAY AREA AFFILIATION OF PARTICIPATING SCHOOL DISTRICTS EMPLOYEE BENEFIT PLAN

PLAN AMENDMENT FOR LINCOLNWAY AREA AFFILIATION OF PARTICIPATING SCHOOL DISTRICTS EMPLOYEE BENEFIT PLAN PLAN AMENDMENT FOR LINCOLNWAY AREA AFFILIATION OF PARTICIPATING SCHOOL DISTRICTS EMPLOYEE BENEFIT PLAN Effective Date: January 1, 2005 This Plan is AMENDED as follows: COBRA CONTINUATION COVERAGE Introduction

More information

SAMPLE FORM OF NOTICE OF CONTINUATION RIGHTS FOR MASSACHUSETTS GROUPS WITH 2-19 ELIGIBLE EMPLOYEES (TO BE DISTRIBUTED WHEN COVERAGE BEGINS)

SAMPLE FORM OF NOTICE OF CONTINUATION RIGHTS FOR MASSACHUSETTS GROUPS WITH 2-19 ELIGIBLE EMPLOYEES (TO BE DISTRIBUTED WHEN COVERAGE BEGINS) SAMPLE FORM OF NOTICE OF CONTINUATION RIGHTS FOR MASSACHUSETTS GROUPS WITH 2-19 ELIGIBLE EMPLOYEES (TO BE DISTRIBUTED WHEN COVERAGE BEGINS) NOTICE OF CONTINUATION RIGHTS FOR QUALIFIED BENEFICIARIES OF

More information

Health Plan Summary Plan Description

Health Plan Summary Plan Description Health Plan Summary Plan Description as amended Effective April 1, 2015 March 31, 2016 This Summary Plan Description ("SPD") explains the main provisions of the Marshfield Clinic Health Systems, Inc. Health

More information

PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION FOR NORTHWEST LABORERS EMPLOYERS HEALTH & SECURITY TRUST FUND REVISED EDITION APRIL 2010

PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION FOR NORTHWEST LABORERS EMPLOYERS HEALTH & SECURITY TRUST FUND REVISED EDITION APRIL 2010 PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION FOR NORTHWEST LABORERS EMPLOYERS HEALTH & SECURITY TRUST FUND REVISED EDITION APRIL 2010 1 NORTHWEST LABORERS-EMPLOYERS HEALTH & SECURITY TRUST FUND INTRODUCTION

More information

ADMINISTRATIVE MANUAL

ADMINISTRATIVE MANUAL CONSOLIDATED COBRA PROCEDURES for DENTAL, HEALTH, VISION and HEALTH CARE REIMBURSEMENT ACCOUNT ADMINISTRATIVE MANUAL Effective January 1, 2012 Revised 12/22/2011 California State University COBRA ADMINISTRATIVE

More information

IMPORTANT INFORMATION ABOUT COBRA CONTINUATION COVERAGE RIGHTS FOR SILVER AND GOLD PARTICIPANTS

IMPORTANT INFORMATION ABOUT COBRA CONTINUATION COVERAGE RIGHTS FOR SILVER AND GOLD PARTICIPANTS IMPORTANT INFORMATION ABOUT COBRA CONTINUATION COVERAGE RIGHTS FOR SILVER AND GOLD PARTICIPANTS 1. What is COBRA Continuation Coverage? COBRA Continuation Coverage ( COBRA Coverage ) is a continuation

More information

SOUTHEASTERN UNIVERSITIES RESEARCH ASSOCIATION

SOUTHEASTERN UNIVERSITIES RESEARCH ASSOCIATION SOUTHEASTERN UNIVERSITIES RESEARCH ASSOCIATION SUMMARY PLAN DESCRIPTION FOR THE CAFETERIA PLAN HEALTH FLEXIBLE SPENDING ACCOUNT PLAN DEPENDENT CARE ASSISTANCE PLAN Effective as of January 1, 2005 INTRODUCTION

More information

ICUBA: Nova Southeastern University PO Box 7127 Atlanta, Georgia

ICUBA: Nova Southeastern University PO Box 7127 Atlanta, Georgia ICUBA: Nova Southeastern University PO Box 7127 Atlanta, Georgia 30357-7127 1-877-747-4141 cobra@csllc.com PARTICIPANT AND DEPENDENT NAME PARTICIPANT ADDRESS Dear Participant and dependent(s): This notice

More information

FAQs For Employees About COBRA Continuation Health Coverage (http://www.dol.gov/ebsa/faqs/faq_consumer_cobra.html) Contents

FAQs For Employees About COBRA Continuation Health Coverage (http://www.dol.gov/ebsa/faqs/faq_consumer_cobra.html) Contents FAQs For Employees About COBRA Continuation Health Coverage (http://www.dol.gov/ebsa/faqs/faq_consumer_cobra.html) Contents Q1: What is COBRA continuation health coverage?... 1 Q2: What does COBRA do?...

More information

COBRA CONTINUATION COVERAGE ELECTION NOTICE

COBRA CONTINUATION COVERAGE ELECTION NOTICE JANE J. DOE & FAMILY 123 MAIN STREET LOS ANGELES, CA 90212 SSN: 123-45-7890 Notification Date: 08/10/2007 Date Your Coverage Ends: 07/31/2007 Last Date to Elect: 10/08/2007 COBRA CONTINUATION COVERAGE

More information

PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN S HEALTH INSURANCE PROGRAM (CHIP). 2 WOMEN S HEALTH AND CANCER RIGHTS ACT ENROLLMENT NOTICE.

PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN S HEALTH INSURANCE PROGRAM (CHIP). 2 WOMEN S HEALTH AND CANCER RIGHTS ACT ENROLLMENT NOTICE. LEGAL NOTICES PREMIUM ASSISTANCE UNDER MEDICAID AND THE CHILDREN S HEALTH INSURANCE PROGRAM (CHIP)... 2 WOMEN S HEALTH AND CANCER RIGHTS ACT ENROLLMENT NOTICE... 6 SPECIAL ENROLLMENT NOTICE... 7 CONTINUATION

More information

SUMMARY PLAN DESCRIPTION * FOR THE TUSCOLA COUNTY MEDICAL CARE FACILITY TUSCOLA COUNTY MEDICAL CARE FACILITY EMPLOYEE BENEFITS PLAN

SUMMARY PLAN DESCRIPTION * FOR THE TUSCOLA COUNTY MEDICAL CARE FACILITY TUSCOLA COUNTY MEDICAL CARE FACILITY EMPLOYEE BENEFITS PLAN [INSURED] SUMMARY PLAN DESCRIPTION * FOR THE TUSCOLA COUNTY MEDICAL CARE FACILITY TUSCOLA COUNTY MEDICAL CARE FACILITY EMPLOYEE BENEFITS PLAN EFFECTIVE APRIL 1, 2018 NON-UNION EMPLOYEES THIS DOCUMENT SHOULD

More information

COLBY COLLEGE STAFF HANDBOOK APPENDIX TABLE OF CONTENTS

COLBY COLLEGE STAFF HANDBOOK APPENDIX TABLE OF CONTENTS COLBY COLLEGE STAFF HANDBOOK APPENDIX TABLE OF CONTENTS Appendix A (Benefit Plan Summary Plan Descriptions)...2 Life...2 Health...5 Long Term Disability...13 Medical Reimbursement...16 Retirement...19

More information

COBRA Continuation Coverage and Qualifying Events

COBRA Continuation Coverage and Qualifying Events CONTINUATION COVERAGE RIGHTS UNDER COBRA You are receiving this Notice of COBRA healthcare coverage continuation rights because you have recently become covered under one or more group health plans. The

More information

An Employee's Guide to Health Benefits Under COBRA

An Employee's Guide to Health Benefits Under COBRA An Employee's Guide to Health Benefits Under COBRA The Consolidated Omnibus Budget Reconciliation Act of 1986 U.S. Department of Labor Employee Benefits Security Administration This publication has been

More information

HEALTH PLAN LEGAL NOTICES. Health Insurance Marketplace Group Health Continuation Coverage Under COBRA Prescription Drug Coverage and Medicare

HEALTH PLAN LEGAL NOTICES. Health Insurance Marketplace Group Health Continuation Coverage Under COBRA Prescription Drug Coverage and Medicare HEALTH PLAN LEGAL NOTICES Health Insurance Marketplace Group Health Continuation Coverage Under COBRA Prescription Drug Coverage and Medicare New Health Insurance Marketplace Coverage Options and Your

More information

Class No, Classification, or Plan Design. Enrollment Information

Class No, Classification, or Plan Design. Enrollment Information OSU Graduate Assistant Health Insurance ENROLLMENT APPLICATION Group Policy. G0021007 Subgroup. P001 Active P002 COBRA Class, Classification, or Plan Design PO Box 7068 Springfield, OR 97475 541.684.5583

More information

JEFFERSON SCIENCE ASSOCIATES, LLC SUMMARY PLAN DESCRIPTION FOR THE CAFETERIA PLAN HEALTH FLEXIBLE SPENDING ACCOUNT PLAN DEPENDENT CARE ASSISTANCE PLAN

JEFFERSON SCIENCE ASSOCIATES, LLC SUMMARY PLAN DESCRIPTION FOR THE CAFETERIA PLAN HEALTH FLEXIBLE SPENDING ACCOUNT PLAN DEPENDENT CARE ASSISTANCE PLAN JEFFERSON SCIENCE ASSOCIATES, LLC SUMMARY PLAN DESCRIPTION FOR THE CAFETERIA PLAN HEALTH FLEXIBLE SPENDING ACCOUNT PLAN DEPENDENT CARE ASSISTANCE PLAN Effective as of June 1, 2006 INTRODUCTION JEFFERSON

More information

RE-ENROLLMENT IS REQUIRED TO ENSURE THAT ALL COMPLIANCE FORMS ARE ON RECORD WITH PCCD.

RE-ENROLLMENT IS REQUIRED TO ENSURE THAT ALL COMPLIANCE FORMS ARE ON RECORD WITH PCCD. Date: August 10, 2006 To: Temporary, Part-time Faculty Members Peralta Federation of Teachers (PFT) members From: Jennifer Seibert, (510) 587-7838-jseibert@peralta.edu Peralta Community College District

More information

COBRA Continuation Coverage Election Notice

COBRA Continuation Coverage Election Notice COBRA Continuation Coverage Election Notice Date: Dear: This notice contains important information about your right to continue your health care coverage in the Health Benefits Plan. Please read the information

More information

SUMMARY PLAN DESCRIPTION OF THE. Triton ISD #2125 Retiree Only Health Reimbursement Arrangement. Effective Date: January 1, 2014

SUMMARY PLAN DESCRIPTION OF THE. Triton ISD #2125 Retiree Only Health Reimbursement Arrangement. Effective Date: January 1, 2014 SUMMARY PLAN DESCRIPTION OF THE Triton ISD #2125 Retiree Only Health Reimbursement Arrangement Effective Date: January 1, 2014 TABLE OF CONTENTS ARTICLE I. INTRODUCTION... 3 GENERAL INFORMATION ABOUT THE

More information

Your Health. Welfare Plan. January 2007

Your Health. Welfare Plan. January 2007 Your Health & Welfare Plan January 2007 Graphic Communications National Health and Welfare Fund Five Gateway Center, Suite 620 60 Boulevard of the Allies Pittsburgh, PA 15222-1219 (800) 943-4248 (GCIU)

More information

Cloquet Public School ISD #94 HEALTH REIMBURSEMENT ARRANGEMENT HRA Summary Plan Description

Cloquet Public School ISD #94 HEALTH REIMBURSEMENT ARRANGEMENT HRA Summary Plan Description Cloquet Public School ISD #94 HEALTH REIMBURSEMENT ARRANGEMENT HRA Summary Plan Description 1 HEALTH REIMBURSEMENT ARRANGEMENT INTRODUCTION We are pleased to announce that we have established a medical

More information

Health Care Benefits. Important!

Health Care Benefits. Important! Health Care Benefits The Major League Baseball Players Welfare Plan (referred to as the Welfare Plan in this section) provides comprehensive health care benefits for you and your eligible dependents. Whether

More information

LOS ANGELES POLICE RELIEF ASSOCIATION, INC. HEALTH CARE BENEFITS ELIGIBILITY BOOKLET FOR ACTIVE MEMBERS

LOS ANGELES POLICE RELIEF ASSOCIATION, INC. HEALTH CARE BENEFITS ELIGIBILITY BOOKLET FOR ACTIVE MEMBERS LOS ANGELES POLICE RELIEF ASSOCIATION, INC. HEALTH CARE BENEFITS ELIGIBILITY BOOKLET FOR ACTIVE MEMBERS Updated as of April 1, 2017 TABLE OF CONTENTS 1. INTRODUCTION... 1 2. ACTIVE MEMBER ELIGIBILITY...

More information

CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA)

CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) Office of Employee Benefits Administrative Manual CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT (COBRA) 250 INITIAL EFFECTIVE DATE: SEPTEMBER 1, 2005 LATEST REVISION DATE: AUGUST 1, 2013 PURPOSE: To provide

More information

COBRA Retiree Vision Care and EAP 2

COBRA Retiree Vision Care and EAP 2 COBRA Retiree Vision Care and EAP 2 CONTENTS CONTINUING HEALTH CARE COVERAGE UNDER COBRA... 3 What COBRA Continuation Coverage Is... 3 Eligibility... 3 Responsibility for Notification and Your COBRA Election

More information

Model COBRA Continuation Coverage General Notice Instructions

Model COBRA Continuation Coverage General Notice Instructions Model COBRA Continuation Coverage General Notice Instructions The Department of Labor has developed a model Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) continuation coverage general

More information

DIXON PUBLIC SCHOOLS DISTRICT #170 All Other Staff (hired prior to July 1, 2013) Health Care Plan

DIXON PUBLIC SCHOOLS DISTRICT #170 All Other Staff (hired prior to July 1, 2013) Health Care Plan DIXON PUBLIC SCHOOLS DISTRICT #170 All Other Staff (hired prior to July 1, 2013) Health Care Plan Benefit Booklet/Plan Document Effective September 1, 2006 Restated March 1, 2015 Table of Contents Page

More information

Participating in the Plan

Participating in the Plan This section provides an overview for participating in the Plan offered to eligible Bosch associates, such as elected and nonelected benefits, who is eligible, enrolling for benefits and when coverage

More information

Summary Plan Description

Summary Plan Description Summary Plan Description For the Allegheny College Section 125 Plan Amended and Restated Effective July 1, 2014 This document with the attached documents listed on the final page, constitute the written

More information

IMPORTANT INFORMATION ABOUT YOUR COBRA CONTINUATION COVERAGE RIGHTS University of Michigan Group Health Plan

IMPORTANT INFORMATION ABOUT YOUR COBRA CONTINUATION COVERAGE RIGHTS University of Michigan Group Health Plan IMPORTANT INFORMATION ABOUT YOUR COBRA CONTINUATION COVERAGE RIGHTS University of Michigan Group Health Plan What is COBRA coverage? COBRA coverage is a continuation of Plan coverage required under Federal

More information

A Guide to Your Benefits 2019

A Guide to Your Benefits 2019 A Guide to Your Benefits 2019 Lamers Bus Lines, Inc. offers a comprehensive suite of benefits to promote health and financial security for you and your family. This booklet provides you with a summary

More information

Health Care Plans and COBRA

Health Care Plans and COBRA Health Care Plans and COBRA COBRA provides workers and their families who lose their health benefits the right to choose to continue group health benefits provided by their group health plan for limited

More information

Overview Revised as of January 1, 2013

Overview Revised as of January 1, 2013 Overview Revised as of January 1, 2013 Table of Contents About This Handbook... 4 An Overview of Your Benefits... 6 Fast Facts: Welfare Plans... 6 Quick Reference: Managing Your Benefits Enrollment...

More information

Robert Bosch LLC. Retiree Welfare Benefit Plan. Summary Plan Description

Robert Bosch LLC. Retiree Welfare Benefit Plan. Summary Plan Description Robert Bosch LLC Retiree Welfare Benefit Plan Summary Plan Description This Summary Plan Description (SPD) describes the Retiree Welfare Benefit Plan with benefits based on an April 1 March 31 Plan Year.

More information

Model COBRA Continuation Coverage Election Notice (For use by single-employer group health plans)

Model COBRA Continuation Coverage Election Notice (For use by single-employer group health plans) Model COBRA Continuation Coverage Election Notice (For use by single-employer group health plans) IMPORTANT INFORMATION: COBRA Continuation Coverage and other Health Coverage Alternatives Date of notice:

More information

Important Notices About Your Benefits

Important Notices About Your Benefits PROUDLY SERVING UTAH PUBLIC EMPLOYEES 560 East 200 South» Salt Lake City, UT» 84102-2004» 801-366-7555 or 800-765-7347» www.pehp.org Important Notices About Your Benefits Several important notices about

More information

Model COBRA Continuation Coverage Election Notice Instructions

Model COBRA Continuation Coverage Election Notice Instructions Model COBRA Continuation Coverage Election Notice Instructions The Department of Labor has developed a model Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) continuation coverage election

More information

Model COBRA Continuation Coverage Election Notice (For use by single-employer group health plans)

Model COBRA Continuation Coverage Election Notice (For use by single-employer group health plans) [Enter date of notice] Model COBRA Continuation Coverage Election Notice (For use by single-employer group health plans) Dear: [Identify the qualified beneficiary(ies), by name or status] This notice contains

More information

To elect COBRA continuation coverage, follow the instructions on the following pages to complete the enclosed Election Form and submit it to us.

To elect COBRA continuation coverage, follow the instructions on the following pages to complete the enclosed Election Form and submit it to us. Model Notice in Connection with Extended Election Periods Model COBRA Continuation Coverage Additional Election Notice (For use by group health plans for qualified beneficiaries who are or would be an

More information

Ascension Health FLEXIBLE SPENDING ACCOUNT PLAN SUMMARY PLAN DESCRIPTION ("SPD") St. Thomas Health Services

Ascension Health FLEXIBLE SPENDING ACCOUNT PLAN SUMMARY PLAN DESCRIPTION (SPD) St. Thomas Health Services Ascension Health FLEXIBLE SPENDING ACCOUNT PLAN SUMMARY PLAN DESCRIPTION ("SPD") St. Thomas Health Services TABLE OF CONTENTS INTRODUCTION TO THE FLEXIBLE SPENDING ACCOUNT PLAN SUMMARY PLAN DESCRIPTION...

More information

COBRA Is An Employer Law

COBRA Is An Employer Law COBRA Is An Employer Law It is the responsibility of the employer to understand all the requirements of the federal COBRA law and fully comply with its requirements. The information contained in this manual,

More information

********IMPORTANT NOTICE********

********IMPORTANT NOTICE******** ********IMPRTANT NTICE******** Subscriber (and/or Spouse) Name Address 1 Address 2 City, State, Zip Date of Notice: Benefits Termination Date: Election Rights Expire on: Subscriber or Member ID Number:

More information

SUMMARY PLAN DESCRIPTION KAISER ALUMINUM SALARIED RETIREES VEBA PLAN

SUMMARY PLAN DESCRIPTION KAISER ALUMINUM SALARIED RETIREES VEBA PLAN SUMMARY PLAN DESCRIPTION KAISER ALUMINUM SALARIED RETIREES VEBA PLAN January 1, 2017 NOTE: The information contained in this Summary Plan Description provides a limited description of the relevant provisions

More information

THE WOODSTOCK FOUNDATION, INC.

THE WOODSTOCK FOUNDATION, INC. THE WOODSTOCK FOUNDATION, INC. Founded by Mary French & Laurance Spelman Rockefeller Date: December 15, 2015 To: All Staff From: Marian Koetsier RE: NEW: Cafeteria Plan Effective January 1, 2016 Effective

More information

ARMSTRONG INTERNATIONAL, INC. THREE RIVERS MI

ARMSTRONG INTERNATIONAL, INC. THREE RIVERS MI ARMSTRONG INTERNATIONAL, INC. THREE RIVERS MI Dental Booklet Revised 01-01-2016 BENEFITS ADMINISTERED BY Table of Contents INTRODUCTION... 3 PLAN INFORMATION... 4 SCHEDULE OF BENEFITS... 6 OUT-OF-POCKET

More information

ST. OLAF COLLEGE FLEXIBLE BENEFITS PLAN SUMMARY PLAN DESCRIPTION. As Amended and Restated Effective April 2012 (unless otherwise indicated)

ST. OLAF COLLEGE FLEXIBLE BENEFITS PLAN SUMMARY PLAN DESCRIPTION. As Amended and Restated Effective April 2012 (unless otherwise indicated) ST. OLAF COLLEGE FLEXIBLE BENEFITS PLAN SUMMARY PLAN DESCRIPTION As Amended and Restated Effective April 2012 (unless otherwise indicated) ST. OLAF COLLEGE FLEXIBLE BENEFITS PLAN SUMMARY PLAN DESCRIPTION

More information

ELWOOD STAFFING SERVICES, INC. COLUMBUS IN

ELWOOD STAFFING SERVICES, INC. COLUMBUS IN ELWOOD STAFFING SERVICES, INC. COLUMBUS IN Dental Benefit Summary Plan Description 7670-09-411299 Revised 01-01-2017 BENEFITS ADMINISTERED BY Table of Contents INTRODUCTION... 1 PLAN INFORMATION... 2 SCHEDULE

More information

CITY OF STOCKTON FLEXIBLE BENEFITS PLAN PLAN SUMMARY

CITY OF STOCKTON FLEXIBLE BENEFITS PLAN PLAN SUMMARY CITY OF STOCKTON FLEXIBLE BENEFITS PLAN PLAN SUMMARY CITY OF STOCKTON FLEXIBLE BENEFITS PLAN PLAN SUMMARY The City of Stockton maintains the City of Stockton Flexible Benefits Plan (the "Plan") for the

More information

COBRA and State Continuation Coverage Plan Year Instructions and Premium Rates

COBRA and State Continuation Coverage Plan Year Instructions and Premium Rates COBRA and State Continuation Coverage 2017-2018 Plan Year Instructions and Premium Rates To: College of Veterinary Medicine Residents and Interns (Employees), Spouses, and/or Dependent Children who lose

More information

HIPAA Special Enrollment Rights Legislative Alert June 9, 2015

HIPAA Special Enrollment Rights Legislative Alert June 9, 2015 Provided by BB&T Insurance Services, Inc., McGriff, Seibels & Williams, Inc., BB&T Insurance Services of California, Inc., and Precept Insurance Solutions, LLC HIPAA Special Enrollment Rights Legislative

More information

ARTICLE 2. ELIGIBILITY FOR BENEFITS

ARTICLE 2. ELIGIBILITY FOR BENEFITS basis must obtain Preadmission Review and Concurrent Review from the Professional Review Organization (PRO) under contract to the Fund as to the Medical Necessity of that confinement in order to receive

More information

Employee Assistance Program (EAP)

Employee Assistance Program (EAP) S U M M A R Y P L A N D E S C R I P T I O N L3 Technologies, Inc. Employee Assistance Program (EAP) Effective January 1, 2017 Table of Contents The Employee Assistance Program (EAP) 1 Eligibility and Participation

More information