Page 23 - 15NH Intertek
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Intertek U.S.A.
Model General Notice of COBRA Continuation X Your spouse dies;
Coverage Rights X Your spouse’s hours of employment are
reduced;
** Continuation Coverage Rights Under COBRA** X Your spouse’s employment ends for
Introduction any reason other than his or her gross
You’re getting this notice because you recently gained coverage under a group misconduct;
health plan (the Plan). This notice has important information about your right to X Your spouse becomes entitled to
COBRA continuation coverage, which is a temporary extension of coverage under Medicare beneits (under Part A, Part B,
the Plan. This notice explains COBRA continuation coverage, when it may or both); or
become available to you and your family, and what you need to do to
protect your right to get it. When you become eligible for COBRA, you may X You become divorced or legally
also become eligible for other coverage options that may cost less than COBRA separated from your spouse
continuation coverage. Your dependent children will become
The right to COBRA continuation coverage was created by a federal law, the qualiied beneiciaries if they lose coverage
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA under the Plan because of the following
continuation coverage can become available to you and other members of your qualifying events:
family when group health coverage would otherwise end. For more information X The parent-employee dies;
about your rights and obligations under the Plan and under federal law, you should X The parent-employee’s hours of
review the Plan’s Summary Plan Description or contact the Plan Administrator. employment are reduced;
You may have other options available to you when you lose group health X The parent-employee’s employment
coverage. For example, you may be eligible to buy an individual plan through the ends for any reason other than his or
Health Insurance Marketplace. By enrolling in coverage through the Marketplace, her gross misconduct;
you may qualify for lower costs on your monthly premiums and lower out-of-pocket X The parent-employee becomes entitled
costs. Additionally, you may qualify for a 30-day special enrollment period for to Medicare beneits (Part A, Part B, or
another group health plan for which you are eligible (such as a spouse’s plan), even both);
if that plan generally doesn’t accept late enrollees.
X The parents become divorced or legally
What is COBRA Continuation Coverage? separated; or
COBRA continuation coverage is a continuation of Plan coverage when it would X The child stops being eligible for
otherwise end because of a life event. This is also called a “qualifying event.” coverage under the Plan as a
Speciic qualifying events are listed later in this notice. After a qualifying event, “dependent child”
COBRA continuation coverage must be offered to each person who is a “qualiied When is COBRA Continuation
beneiciary.” You, your spouse, and your dependent children could become qualiied Coverage Available?
beneiciaries if coverage under the Plan is lost because of the qualifying event. The Plan will offer COBRA continuation
Under the Plan, qualiied beneiciaries who elect COBRA continuation coverage coverage to qualiied beneiciaries only after
must pay for COBRA continuation coverage.
the Plan Administrator has been notiied
If you’re an employee, you’ll become a qualiied beneiciary if you lose your that a qualifying event has occurred. The
coverage under the Plan because of the following qualifying events: employer must notify the Plan Administrator
X Your hours of employment are reduced; or of the following qualifying events:
X Your employment ends for any reason other than your gross misconduct X The end of employment or reduction of
hours of employment;
If you’re the spouse of an employee, you’ll become a qualiied beneiciary if you X Death of the employee;
lose your coverage under the Plan because of the following qualifying events:
23
Model General Notice of COBRA Continuation X Your spouse dies;
Coverage Rights X Your spouse’s hours of employment are
reduced;
** Continuation Coverage Rights Under COBRA** X Your spouse’s employment ends for
Introduction any reason other than his or her gross
You’re getting this notice because you recently gained coverage under a group misconduct;
health plan (the Plan). This notice has important information about your right to X Your spouse becomes entitled to
COBRA continuation coverage, which is a temporary extension of coverage under Medicare beneits (under Part A, Part B,
the Plan. This notice explains COBRA continuation coverage, when it may or both); or
become available to you and your family, and what you need to do to
protect your right to get it. When you become eligible for COBRA, you may X You become divorced or legally
also become eligible for other coverage options that may cost less than COBRA separated from your spouse
continuation coverage. Your dependent children will become
The right to COBRA continuation coverage was created by a federal law, the qualiied beneiciaries if they lose coverage
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA under the Plan because of the following
continuation coverage can become available to you and other members of your qualifying events:
family when group health coverage would otherwise end. For more information X The parent-employee dies;
about your rights and obligations under the Plan and under federal law, you should X The parent-employee’s hours of
review the Plan’s Summary Plan Description or contact the Plan Administrator. employment are reduced;
You may have other options available to you when you lose group health X The parent-employee’s employment
coverage. For example, you may be eligible to buy an individual plan through the ends for any reason other than his or
Health Insurance Marketplace. By enrolling in coverage through the Marketplace, her gross misconduct;
you may qualify for lower costs on your monthly premiums and lower out-of-pocket X The parent-employee becomes entitled
costs. Additionally, you may qualify for a 30-day special enrollment period for to Medicare beneits (Part A, Part B, or
another group health plan for which you are eligible (such as a spouse’s plan), even both);
if that plan generally doesn’t accept late enrollees.
X The parents become divorced or legally
What is COBRA Continuation Coverage? separated; or
COBRA continuation coverage is a continuation of Plan coverage when it would X The child stops being eligible for
otherwise end because of a life event. This is also called a “qualifying event.” coverage under the Plan as a
Speciic qualifying events are listed later in this notice. After a qualifying event, “dependent child”
COBRA continuation coverage must be offered to each person who is a “qualiied When is COBRA Continuation
beneiciary.” You, your spouse, and your dependent children could become qualiied Coverage Available?
beneiciaries if coverage under the Plan is lost because of the qualifying event. The Plan will offer COBRA continuation
Under the Plan, qualiied beneiciaries who elect COBRA continuation coverage coverage to qualiied beneiciaries only after
must pay for COBRA continuation coverage.
the Plan Administrator has been notiied
If you’re an employee, you’ll become a qualiied beneiciary if you lose your that a qualifying event has occurred. The
coverage under the Plan because of the following qualifying events: employer must notify the Plan Administrator
X Your hours of employment are reduced; or of the following qualifying events:
X Your employment ends for any reason other than your gross misconduct X The end of employment or reduction of
hours of employment;
If you’re the spouse of an employee, you’ll become a qualiied beneiciary if you X Death of the employee;
lose your coverage under the Plan because of the following qualifying events:
23
