Page 21 - 2016 WFF Guide 1
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M od el C O B R A G eneral N otice
R e: C ontinuation C ov erage R ights U nd er C O B R A
Y ou are receiv ing this N otice of C O B R A healthcare cov erage continuation rights
because you hav e recently become cov ered und er one or more group health plans.
The plan ( or plans) und er w hich you hav e gained cov erage are listed at the end of this
F orm, and are referred to collectiv ely as “ the plan” ex cept w here otherw ise ind icated .
This notice contains important information about your right to C O B R A continuation
cov erage, w hich is a temporary ex tension of healthcare cov erage und er the plan. The
right to C O B R A continuation cov erage w as created by a fed eral law , the C onsolid ated
O mnibus B ud get R econciliation A ct of 1 9 8 5 ( C O B R A ) . C O B R A continuation cov erage
can become av ailable to you and / or to other members of your family w ho are cov ered
und er the plan w hen you and / or they w ould otherw ise lose the group health cov erage.
This notice giv es only a summary of your C O B R A continuation cov erage rights. This
notice generally ex plains C O B R A continuation cov erage, w hen it may become av ailable
to you and your family, and w hat you need to d o to protect the right to receiv e it. F or
more information about your rights and obligations und er the plan and und er fed eral
law , you should either rev iew the plan’ s S ummary P lan D escription or contact the P lan
A d ministrator. I n some cases the plan d ocument also serv es as the S ummary P lan
D escription.
N ote: you may hav e other options av ailable to you w hen you lose group health
cov erage. W hen you become eligible for C O B R A , you may also become eligible for
other cov erage options not prov id ed by your employer that may cost less than C O B R A
continuation cov erage. F or ex ample, you may be eligible to buy an ind iv id ual plan
through the H ealth I nsurance M ark etplace. B y enrolling in cov erage through the
M ark etplace, you may q ualify for low er costs on your monthly premiums and low er
out- of- pock et costs. A d d itionally, you may q ualify for a 3 0 - d ay special enrollment
period for another group health plan for w hich you are eligible ( such as a spouse’ s
plan) , ev en if that plan generally d oesn’ t accept late enrollees.
C O B R A C ontinuation C ov erage and “ Q ualifying E v ents”
C O B R A continuation cov erage is a continuation of plan cov erage w hen cov erage w ould
otherwise end because of a life event known as a “qualifying event.” Speciic qualifying
ev ents are listed later in this notice. C O B R A continuation cov erage must be offered to
each person who is a “qualiied beneiciary.” A qualiied beneiciary is someone who
w ill lose cov erage und er the plan because of a q ualifying ev ent. D epend ing on the
type of q ualifying ev ent, employees, spouses of employees, and eligible child ren of
employees may be qualiied beneiciaries. Certain newborns, newly-adopted children
and alternate recipients under qualiied medical child support orders may also be
qualiied beneiciaries. This is discussed in more detail in separate paragraphs below.
Under the plan, qualiied beneiciaries who elect COBRA continuation coverage
generally must pay for this continuation cov erage.
2016 Open Enrollment
M od el C O B R A G eneral N otice
R e: C ontinuation C ov erage R ights U nd er C O B R A
Y ou are receiv ing this N otice of C O B R A healthcare cov erage continuation rights
because you hav e recently become cov ered und er one or more group health plans.
The plan ( or plans) und er w hich you hav e gained cov erage are listed at the end of this
F orm, and are referred to collectiv ely as “ the plan” ex cept w here otherw ise ind icated .
This notice contains important information about your right to C O B R A continuation
cov erage, w hich is a temporary ex tension of healthcare cov erage und er the plan. The
right to C O B R A continuation cov erage w as created by a fed eral law , the C onsolid ated
O mnibus B ud get R econciliation A ct of 1 9 8 5 ( C O B R A ) . C O B R A continuation cov erage
can become av ailable to you and / or to other members of your family w ho are cov ered
und er the plan w hen you and / or they w ould otherw ise lose the group health cov erage.
This notice giv es only a summary of your C O B R A continuation cov erage rights. This
notice generally ex plains C O B R A continuation cov erage, w hen it may become av ailable
to you and your family, and w hat you need to d o to protect the right to receiv e it. F or
more information about your rights and obligations und er the plan and und er fed eral
law , you should either rev iew the plan’ s S ummary P lan D escription or contact the P lan
A d ministrator. I n some cases the plan d ocument also serv es as the S ummary P lan
D escription.
N ote: you may hav e other options av ailable to you w hen you lose group health
cov erage. W hen you become eligible for C O B R A , you may also become eligible for
other cov erage options not prov id ed by your employer that may cost less than C O B R A
continuation cov erage. F or ex ample, you may be eligible to buy an ind iv id ual plan
through the H ealth I nsurance M ark etplace. B y enrolling in cov erage through the
M ark etplace, you may q ualify for low er costs on your monthly premiums and low er
out- of- pock et costs. A d d itionally, you may q ualify for a 3 0 - d ay special enrollment
period for another group health plan for w hich you are eligible ( such as a spouse’ s
plan) , ev en if that plan generally d oesn’ t accept late enrollees.
C O B R A C ontinuation C ov erage and “ Q ualifying E v ents”
C O B R A continuation cov erage is a continuation of plan cov erage w hen cov erage w ould
otherwise end because of a life event known as a “qualifying event.” Speciic qualifying
ev ents are listed later in this notice. C O B R A continuation cov erage must be offered to
each person who is a “qualiied beneiciary.” A qualiied beneiciary is someone who
w ill lose cov erage und er the plan because of a q ualifying ev ent. D epend ing on the
type of q ualifying ev ent, employees, spouses of employees, and eligible child ren of
employees may be qualiied beneiciaries. Certain newborns, newly-adopted children
and alternate recipients under qualiied medical child support orders may also be
qualiied beneiciaries. This is discussed in more detail in separate paragraphs below.
Under the plan, qualiied beneiciaries who elect COBRA continuation coverage
generally must pay for this continuation cov erage.
2016 Open Enrollment
