EXPLANATION OF USE FOR THE MODEL GENERAL NOTICE This memorandum is being provided to explain the use of the Model General Notice which is attached hereto. By way of explanation, on May 26, 2004 the United States Department of Labor issued final rules specifying the required content and timing of notices required by the health care continuation coverage provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (“COBRA”). The attached Model General Notice was a part of those final rules and should be used by you as the employer or by your Plan Administrator. As a courtesy to our customers, we are providing this Model General Notice as a guide for developing your group’s Model General Notice. Please remember, if your group is not subject to COBRA then you will not need to utilize this notice. Your Model General Notice should include the name of the plan and the name, address and telephone number of the party responsible under the plan for administering COBRA benefits, in that connection, it will be necessary for the provided Model General Notice to be altered to include that information. This Model General Notice must be sent to an employee and the employee’s spouse within 90 days of the date on which any such individual’s coverage commences under the plan. As stated above, this notice must be provided to the employee and the employee’s spouse, however, a separate Model General Notice is not required for dependant children residing with an employee or with the employee’s spouse. DISCLAIMER - Nothing contained, expressed, or implied in this Explanation of Use for the Model General Notice or the Model General Notice attached hereto is intended as, nor shall be construed or understood as, legal advice, guidance, or interpretation. No attorney-client relationship is established between Blue Cross & Blue Shield of Mississippi and you by reason of your use of this Explanation of Use for the Model General Notice or the Model General Notice attached hereto under any circumstances whatsoever. The Explanation of Use for the Model General Notice and the Model General Notice attached hereto are provided for general information purposes only. If you have questions about any law, statute, regulation, or requirement expressly or implicitly referenced by this Explanation of Use for the Model General Notice or the Model General Notice attached hereto, you should contact your own legal counsel. COBRA administration and notice requirements remain the sole responsibility of the employer or Plan Administrator and by the provision of this Explanation of Use for the Model General Notice and the Model General Notice attached hereto; Blue Cross & Blue Shield of Mississippi assumes none of that responsibility. BCBS 21198 MODEL GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS (For use by single-employer group health plans) ** CONTINUATION COVERAGE RIGHTS UNDER COBRA** Introduction You are receiving this notice because you have recently become covered under a group health plan (the Plan). This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation 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 federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator. What is COBRA Continuation Coverage? COBRA continuation 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, COBRA continuation 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. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage [choose and enter appropriate information: must pay or are not required to pay] for COBRA continuation coverage. If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the following qualifying events happens: • Your hours of employment are reduced, or • Your employment ends for any reason other than your gross misconduct. If you are the spouse of an employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any of the following qualifying events happens: • Your spouse dies; • Your spouse’s hours of employment are reduced; • Your spouse’s employment ends for any reason other than his or her gross misconduct; • Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or • You become divorced or legally separated from your spouse. BCBS 21198 Your dependent children will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying events happens: • The parent-employee dies; • The parent-employee’s hours of employment are reduced; • The parent-employee’s employment ends for any reason other than his or her gross misconduct; • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both); • The parents become divorced or legally separated; or • The child stops being eligible for coverage under the plan as a “dependent child.” W T A i P r A Y F d P P a i H O c b B [If the Plan provides retiree health coverage, add the following paragraph:] Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be a qualifying event. If a proceeding in bankruptcy is filed with respect to [enter name of employer sponsoring the plan], and that bankruptcy results in the loss of coverage of any retired employee covered under the Plan, the retired employee will become a qualified beneficiary with respect to the bankruptcy. The retired employee’s spouse, surviving spouse, and dependent children will also become qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. hen is COBRA Coverage Available? he Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan dministrator has been notified that a qualifying event has occurred. When the qualifying event s the end of employment or reduction of hours of employment, death of the employee, [add if lan provides retiree health coverage: commencement of a proceeding in bankruptcy with espect to the employer,] or the employee's becoming entitled to Medicare benefits (under Part , Part B, or both), the employer must notify the Plan Administrator of the qualifying event. ou Must Give Notice of Some Qualifying Events or the other qualifying events (divorce or legal separation of the employee and spouse or a ependent child’s losing eligibility for coverage as a dependent child), you must notify the lan Administrator within 60 days [or enter longer period permitted under the terms of the lan] after the qualifying event occurs. You must provide this notice to: [Enter name of ppropriate party]. [Add description of any additional Plan procedures for this notice, ncluding a description of any required information or documentation.] ow is COBRA Coverage Provided? nce the Plan Administrator receives notice that a qualifying event has occurred, COBRA ontinuation coverage will be offered to each of the qualified beneficiaries. Each qualified eneficiary will have an independent right to elect COBRA continuation coverage. Covered CBS 21198 2 employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a dependent child's losing eligibility as a dependent child, COBRA continuation 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, COBRA continuation 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 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation coverage can be extended. Disability extension of 18-month period of continuation coverage If you or anyone in your family covered under the Plan is determined by the Social Security Administration to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. [Add description of any additional Plan procedures for this notice, including a description of any required information or documentation, the name of the appropriate party to whom notice must be sent, and the time period for giving notice.] Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the Plan. This extension may be available to the spouse and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, 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. BCBS 21198 3 BCBS 21198 4 If You Have Questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, 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 website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) Keep Your Plan Informed of Address Changes In order to protect your family’s rights, you should keep the Plan 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 the Plan Administrator. Plan Contact Information [Enter name of group health plan and name (or position), address and phone number of party or parties from whom information about the plan and COBRA continuation coverage can be obtained on request.]