Page 26 - Great Circle 2021 Benefits Guide
P. 26
Second Qualifying Event Extension of Keep Your Plan Informed of Address
18-Month Period of Continuation Coverage Changes
If your family experiences another qualifying event while In order to protect your family’s rights, you should keep the
receiving COBRA continuation coverage, the spouse and Plan Administrator informed of any changes in the addresses of
dependent children in your family can get additional months family members. You should also keep a copy, for your records,
of COBRA continuation coverage, up to a maximum of 36 of any notices you send to the Plan Administrator.
months. This extension may be available to the spouse and
any dependent children receiving continuation coverage if Plan Contact Information
the employee or former employee dies, becomes entitled Great Circle
to Medicare beneits (under Part A, Part B, or both), or gets P.O. Box 189
divorced or legally separated, or if the dependent child stops St. James, Missouri 65559
being eligible under the Plan as a dependent child, but only if
the event would have caused the spouse or dependent child Model COBRA General Notice
to lose coverage under the Plan had the irst qualifying event
not occurred. In all of these cases, you must make sure that Re: Continuation Coverage Rights Under COBRA
the Plan Administrator is notiied of the second qualifying event You are receiving this Notice of COBRA healthcare coverage
within 60 days of the second qualifying event. continuation rights because you have recently become covered
under one or more group health plans. The plan (or plans)
Are There Other Coverage Options Besides under which you have gained coverage are listed at the end of
COBRA Continuation Coverage? this Form, and are referred to collectively as “the plan” except
Yes. Instead of enrolling in COBRA continuation coverage, where otherwise indicated.
there may be other coverage options for you and your family This notice contains important information about your right
through the Health Insurance Marketplace, Medicaid, or other to COBRA continuation coverage, which is a temporary
group health plan coverage options (such as a spouse’s plan) extension of healthcare coverage under the plan. The right to
through what is called a “special enrollment period.” Some COBRA continuation coverage was created by a federal law,
of these options may cost less than COBRA continuation the Consolidated Omnibus Budget Reconciliation Act of 1985
coverage. You can learn more about many of these options at (COBRA). COBRA continuation coverage can become available
www.healthcare.gov . to you and/or to other members of your family who are covered
If You Have Questions under the plan when you and/or they would otherwise lose the
group health coverage. This notice gives only a summary of
Questions concerning your Plan or your COBRA continuation your COBRA continuation coverage rights. This notice generally
coverage rights should be addressed to the contact or explains COBRA continuation coverage, when it may become
contacts identiied below. For more information about your available to you and your family, and what you need to do to
rights under the Employee Retirement Income Security protect the right to receive it. For more information about your
Act (ERISA), including COBRA, the Patient Protection and rights and obligations under the plan and under federal law,
Afordable Care Act, and other laws afecting group health you should either review the plan’s Summary Plan Description
plans, contact the nearest Regional or District Oice of the or contact the Plan Administrator. In some cases the plan
U.S. Department of Labor’s Employee Beneits Security document also serves as the Summary Plan Description.
Administration (EBSA) in your area or visit the EBSA website
at www.dol.gov/ebsa. (Addresses and phone numbers of
Regional and District EBSA Oices are available through EBSA’s
website.) For more information about the Marketplace, visit
www.HealthCare.gov .
26
18-Month Period of Continuation Coverage Changes
If your family experiences another qualifying event while In order to protect your family’s rights, you should keep the
receiving COBRA continuation coverage, the spouse and Plan Administrator informed of any changes in the addresses of
dependent children in your family can get additional months family members. You should also keep a copy, for your records,
of COBRA continuation coverage, up to a maximum of 36 of any notices you send to the Plan Administrator.
months. This extension may be available to the spouse and
any dependent children receiving continuation coverage if Plan Contact Information
the employee or former employee dies, becomes entitled Great Circle
to Medicare beneits (under Part A, Part B, or both), or gets P.O. Box 189
divorced or legally separated, or if the dependent child stops St. James, Missouri 65559
being eligible under the Plan as a dependent child, but only if
the event would have caused the spouse or dependent child Model COBRA General Notice
to lose coverage under the Plan had the irst qualifying event
not occurred. In all of these cases, you must make sure that Re: Continuation Coverage Rights Under COBRA
the Plan Administrator is notiied of the second qualifying event You are receiving this Notice of COBRA healthcare coverage
within 60 days of the second qualifying event. continuation rights because you have recently become covered
under one or more group health plans. The plan (or plans)
Are There Other Coverage Options Besides under which you have gained coverage are listed at the end of
COBRA Continuation Coverage? this Form, and are referred to collectively as “the plan” except
Yes. Instead of enrolling in COBRA continuation coverage, where otherwise indicated.
there may be other coverage options for you and your family This notice contains important information about your right
through the Health Insurance Marketplace, Medicaid, or other to COBRA continuation coverage, which is a temporary
group health plan coverage options (such as a spouse’s plan) extension of healthcare coverage under the plan. The right to
through what is called a “special enrollment period.” Some COBRA continuation coverage was created by a federal law,
of these options may cost less than COBRA continuation the Consolidated Omnibus Budget Reconciliation Act of 1985
coverage. You can learn more about many of these options at (COBRA). COBRA continuation coverage can become available
www.healthcare.gov . to you and/or to other members of your family who are covered
If You Have Questions under the plan when you and/or they would otherwise lose the
group health coverage. This notice gives only a summary of
Questions concerning your Plan or your COBRA continuation your COBRA continuation coverage rights. This notice generally
coverage rights should be addressed to the contact or explains COBRA continuation coverage, when it may become
contacts identiied below. For more information about your available to you and your family, and what you need to do to
rights under the Employee Retirement Income Security protect the right to receive it. For more information about your
Act (ERISA), including COBRA, the Patient Protection and rights and obligations under the plan and under federal law,
Afordable Care Act, and other laws afecting group health you should either review the plan’s Summary Plan Description
plans, contact the nearest Regional or District Oice of the or contact the Plan Administrator. In some cases the plan
U.S. Department of Labor’s Employee Beneits Security document also serves as the Summary Plan Description.
Administration (EBSA) in your area or visit the EBSA website
at www.dol.gov/ebsa. (Addresses and phone numbers of
Regional and District EBSA Oices are available through EBSA’s
website.) For more information about the Marketplace, visit
www.HealthCare.gov .
26
