Continuation of Coverage

Continuation of Coverage

 
Family and Medical Leave Act

An employee may continue coverage in this health plan as provided by the Family and Medical Leave Act. (The Family and Medical Leave Act generally applies to you if your group has 50 or more employees.) An employee who has been employed at least one year and worked at least 1,250 hours within the previous 12 months is eligible to choose to continue coverage for up to 12 weeks of unpaid leave for any one of the following reasons.

  • The birth of the employee’s child.
  • The placement of a child with the employee for the purpose of adoption or foster care.
  • To care for a seriously ill spouse, child, or parent.
  • A serious health condition rendering the employee unable to perform his or her job.

If the employee chooses to continue group coverage during the leave, the employee will be given the same health care benefits that would have been provided if the employee were working, with the same premium contribution ratio. If the employee’s premium for continued coverage under the group plan is more than 30 days late, the plan sponsor will send written notice to the employee. It will tell the employee that his or her coverage will be terminated. It will also give the date of the termination if payment is not received by that date. This notice will be mailed at least 15 days before the termination date.

If coverage in this health plan under the group plan is discontinued due to non-payment of premium, the employee’s coverage will be restored when he or she returns to work to the same level of benefits as those the employee would have had if the leave had not been taken and the premium payment(s) had not been missed. This includes coverage for eligible dependents. The employee will not be required to meet any qualification requirements imposed by the group when he or she returns to work. This includes: new or additional waiting periods; waiting for an open enrollment period; or passing a medical exam to reinstate coverage. You should contact your plan sponsor with any questions that you may have about your coverage during a leave of absence.

Continuation of Group Coverage Under Federal Law

When you are no longer eligible for coverage in this health plan under a group plan, you may be eligible to continue group coverage as provided by the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). To continue this group coverage, you may be required to pay up to 102% of the premium cost. These laws apply to you if you lose eligibility for coverage due to one of the following reasons.

  • Termination of employment (for reasons other than gross misconduct).
  • Reduction of work hours.
  • Divorce or legal separation. (In the event of divorce or legal separation, a spouse is eligible to keep coverage in this health plan under the employee’s group plan. This is the case only until the employee is no longer required by law to provide health insurance for the former spouse or the employee or former spouse remarries, whichever comes first. The former spouse’s eligibility for continued group coverage will start on the date of divorce, even if he or she continues coverage under the employee’s group plan. While the former spouse continues coverage under the employee’s group plan, there is no additional premium. After remarriage, under state and federal law, the former spouse may be eligible to continue group coverage in this health plan under a separate group plan for additional premium.)
  • Death of the subscriber.
  • Subscriber’s entitlement to Medicare benefits.
  • Loss of status as an eligible dependent.

The period of this continued group coverage begins with the date of your qualifying event. And, the length of this continued group coverage will be up to 36 months from that qualifying event. This is true except for termination of employment or reduction of work hours, in which cases continued group coverage is available for only 18 months or, if you are qualified for disability under Title II or Title XVI of the Social Security Act, up to 29 months. (See below for more information about continued coverage for disabled employees.) You should contact your plan sponsor for more help about continued coverage.

Important Note: When a subscriber’s legal same-sex spouse or domestic partner is no longer eligible for coverage under the group plan, that spouse (or if it applies, that civil union spouse or domestic partner) and his or her dependents may continue coverage in the subscriber’s group to the same extent that a legal opposite-sex spouse (and his or her dependents) could continue coverage upon loss of eligibility for coverage under the group plan.

Additional Continued Coverage for Disabled Employees
Within 60 days of the employee’s termination of employment or reduction in hours, if an employee or his or her eligible dependent is determined to be disabled under Title II or Title XVI of the Social Security Act, continued group coverage will be available for up to 29 months from the date of the qualifying event. The premium cost for the additional 11 months may be up to 150% of the premium rate. If during these 11 months eligibility for disability is lost, group coverage may cancel before the 29 months is completed. You should contact your plan sponsor for more help about continued coverage.

Special Rules for Retired Employees
A retired employee, the spouse, and/or eligible dependent children of a retired employee or a surviving spouse of a retired deceased employee who loses eligibility for coverage in this health plan under the group plan as a result of a bankruptcy proceeding (Title 11 of the United States Code) is also eligible to continue group coverage as provided by COBRA. A retired employee and/or the surviving spouse of a deceased retired employee may enroll for lifetime continued group coverage as of the date of the bankruptcy proceeding, provided that the loss of group eligibility occurs within one year before the date on which the bankruptcy proceeding begins. Or, if group eligibility is lost within one year after the date on which the bankruptcy proceeding begins, they may enroll for lifetime continued group coverage as of the date group eligibility is lost. Spouses and/or eligible dependents of these retired employees may enroll for continued group coverage until the retired employee dies. Once the retired employee dies, his or her surviving spouse and/or eligible dependents may enroll for up to an additional 36 months of continued group coverage beyond the date of the retired employee’s death.

Lifetime continued coverage in this health plan for retired employees will end if the group cancels its agreement with Blue Cross and Blue Shield to provide its group members with coverage in this health plan or for any of the other reasons described below. (See “Termination of Continued Group Coverage.”)

Enrollment for Continued Group Coverage
In order to enroll for continued group coverage in this health plan, you must complete an Election Form. The completed election form must be returned to the office at the address on the form. The form must be returned within 60 days from your date of termination of group coverage or your notification of eligibility, whichever is later. If you do not return the completed form, it will be considered a waiver. And, you will not be allowed to continue coverage in this health plan under a group plan. (The 60 days will be counted from the date of the eligibility notice to the postmarked date of the mailed election form.)

Termination of Continued Group Coverage
Your continued group coverage will end when:

  • The length of time allowed for continued group coverage is reached (for example, 18 months or 29 months or 36 months from the qualifying event).
  • You fail to make timely payment of your premiums.
  • You enroll in another employer sponsored health plan and that plan does not include pre-existing condition limitations or waiting periods.
  • You become entitled to Medicare benefits.
  • You are no longer disabled (if your continued group coverage had been extended because of disability).
  • The group terminates its agreement with Blue Cross and Blue Shield to provide its group members with access to health care services and benefits under this health plan. In this case, health care coverage may continue under another health plan. Contact your plan sponsor or Blue Cross and Blue Shield for more information.
Certificates of Group Health Plan Coverage

As provided by federal law, you are entitled to a certificate that will show evidence of your prior health care coverage. A certificate of prior coverage may help you obtain coverage without a pre-existing condition exclusion even if you buy health insurance other than through an employer group health plan. All members have the right to receive a certificate of group health plan coverage when:

  • The member ceases coverage under the group’s health plan or coverage would have been lost had the member not elected to continue group coverage under COBRA.
  • The member’s continued coverage under COBRA ends.
  • The member requests a certificate of group health plan coverage within 24 months of his or her loss of health care coverage.
  • The member’s claim is denied because he or she has reached a lifetime limit on all benefits (if there is a limit).

While you are enrolled for coverage in this health plan, Blue Cross and Blue Shield will provide this certificate to you. When your coverage under the group plan ends and you are eligible for a certificate of group health plan coverage, the plan sponsor and/or Blue Cross and Blue Shield will provide this certificate to you. It is important that you promptly notify your group when you are terminating your coverage.