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Extended Coverage Participants

Cobra Information

Introduction

This notice applies to you if you are covered under the Commonwealth of Virginia Health Benefits Program (the Plan), including the health benefits plan and, if you elected to enroll, the medical expense flexible reimbursement account. This notice contains important information about your right to temporarily extend your coverage under the Plan. This notice generally explains Extended 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 supersedes any previous General Notice and is being sent to comply with the United States Department of Labor's May 26, 2004, final rules implementing notice requirements of health care continuation coverage under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), which also promulgated parallel provisions of the Public Health Service Act.

The right to Extended Coverage was created for private employers by federal law through COBRA, and these rights are reflected in the continuation coverage provisions of the Public Health Service Act which covers employees of state and local governments. Extended Coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise lose their group health coverage.

For additional information about your rights and obligations under the plan and under the law, you should contact your designated Benefits Administrator. For active employees, this would be the individual designated by your employing agency to administer eligibility for the Plan, including initial Extended Coverage enrollment. For retirees, survivors or long-term disability participants (retiree group participants), this would generally be the Virginia Retirement System. However, local retirees/survivors or optional retirement plan retirees/survivors should contact their pre-retirement agency's Benefits Administrator. Contact the Human Resources Department of the appropriate entity (as previously noted) if you need assistance in determining the name and mailing address of your specific Benefits Administrator. Resources for additional information are provided on page 4.

What is Extended Coverage?

Extended 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 this notice. After a qualifying event, Extended Coverage must be offered to each person who is a "qualified beneficiary." You, your spouse and your dependent children could become qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. These rights are also available to children covered through a Qualified Medical Child Support Order (QMCSO). Under the Plan, qualified beneficiaries who elect Extended Coverage must pay the full cost for Extended Coverage. Time limitations for making Extended Coverage premium payments will be included in the Election Notice provided at the time of the qualifying event.

If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because of either one of the following qualifying events:

If you are the spouse of an employee or retiree group participant, you will become a qualified beneficiary if you lose your coverage under the plan because of any one of the following qualifying events:

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because of any one of the following qualifying events:

Coverage that is terminated in anticipation of a qualifying event (e.g., divorce) is disregarded when determining whether the event results in a loss of coverage. If termination occurs under this condition but notification of the qualifying event is received from the employee, qualified beneficiary or a representative within 60 days of the date coverage would have been lost due to the qualifying event, Extended Coverage must be made available and effective on the date coverage would have been lost due to the event, but not before.

When is Extended Coverage Available?

Your Benefits Administrator will automatically offer Extended Coverage to qualified beneficiaries upon the occurrence of the following qualifying events:

You Must Give Notice of Some Qualifying Events

For the other qualifying events (divorce of the employee and spouse or a dependent child's loss of eligibility for coverage as a dependent child), you or your representative must notify your Benefits Administrator within 60 days of the qualifying event (or within 60 days of the date coverage would be lost due to the qualifying event) by submitting written notification to include the following information:

Failure to provide timely notice of these qualifying events will result in loss of eligibility for continuation coverage. One notice will cover all affected qualified beneficiaries. Notice will be considered furnished when mailed or, in the case of hand delivery, the date it is received by your Benefits Administrator.

How is Extended Coverage Provided?

Once the designated Commonwealth of Virginia Benefits Administrator becomes aware or is notified that the qualifying event has occurred, Extended Coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect Extended Coverage. Covered employees may elect Extended Coverage on behalf of an eligible spouse, and parents may elect Extended Coverage on behalf of their eligible children.

Extended Coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee/retiree, your divorce, or a dependent child's loss of eligibility as a dependent child, Extended Coverage lasts for up to a total of 36 months. When the qualifying event is the end of employment or reduction of the employee's hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, Extended Coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare eight months before his coverage ends due to termination of employment, Extended Coverage for his covered spouse and/or children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date that coverage was lost due to termination of employment (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of employee's hours of employment, Extended Coverage may last for only up to a total of 18 months. There are two ways in which this 18-month period can be extended.

1.) Disability extension of 18-month period of continuation coverage

You and anyone in your family covered under the Extended Coverage provisions of the Plan (due to termination of employment or reduction of hours) may be entitled to receive up to an additional 11 months of continuation coverage if it is determined by the Social Security Administration that any covered family member is disabled at some time during the first 60 days of continuation coverage, and the disability lasts at least until the end of the 18-month initial period of continuation coverage. The Office of Health Benefits Extended Coverage Administrator (see page 4) must receive notification of the disability determination within 60 days of either 1.) the date of the disability determination; 2.) the date of the qualifying event; 3.) the date on which coverage would be lost due to the qualifying event; or, 4.) the date on which the qualified beneficiary is informed of the obligation to provide the disability notice (e.g., through this General Notice), AND within the first 18 months of Extended Coverage. Notification must be presented in writing and include the following information:

2.) Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event while receiving 18 months of Extended Coverage, the spouse and dependent children in your family can get up to 18 additional months of continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given (in the format and time frame specified below) to the Office of Health Benefits Extended Coverage Administrator (see page 4). The extension may be available to the spouse and any dependent children receiving continuation coverage if the employee/former employee dies, the employee/former employee becomes divorced from the covered spouse, or the covered dependent child ceases to be eligible under the Plan, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. Written notification must be given within 60 days of the date coverage would have been lost due to the second qualifying event and should include the following information:

Failure to furnish timely and complete notification of the second qualifying event or disability determination will result in loss of additional Extended Coverage eligibility. Notice will be considered furnished when mailed or, in the case of hand delivery, furnished on the date it is received by your Benefits Administrator.

Separate guidelines apply to continuation coverage under the provisions of the Uniform Services Employment and Re-employment Rights Act of 1994 (USERRA). If these provisions apply to you, see your Benefits Administrator for more information.

If you have questions:

Questions concerning your Plan or your Extended Coverage rights should be addressed to the contacts listed below under "Plan contact information." For more information about your continuation coverage rights under the Public Health Service Act or under the Health Insurance Portability and Accountability Act, contact the nearest regional or district office of the U. S. Department of Labor's Employee Benefits Security Administration (EBSA) in your area or visit the EBSA Web site at www.dol.gov/ebsa . Addresses and phone numbers of regional and district EBSA Offices are available on the Web site, but if you live in Virginia, the district office is:

Washington District Office
1335 East-West Highway, Suite 200
Silver Spring, MD 20910
Telephone: 301/713-2000

Keep your Benefits Administrator informed of address changes

In order to protect your family's rights, you should keep your Benefits 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 your Benefits Administrator or the Office of Health Benefits Extended Coverage Administrator.

The Plan Administrator is:

The Department of Human Resource Management
101 N. 14 th Street, 13 th Floor
Richmond, Virginia 23219

Plan contact information

For information about Extended Coverage, initial notification of qualifying events, and initial enrollment, contact your agency Benefits Administrator (see page 1).

To makes changes to Extended Coverage after initial enrollment, contact:

Office of Health Benefits Extended Coverage Administrator
101 N. 14th Street
13th Floor
Richmond, VA 23219
Telephone: 804-225-3642 in Richmond
or
1-888-OHB-4414 (888-642-4414).