[Enter date of notice]
RE: Cal-COBRA Continuation Coverage Election Notice
Dear[Identify the qualified beneficiary(ies), by name or status]:
This notice contains important information about additional rights to continue your health care coverage in your group dental health plan, which your employer arranges through Delta Dental. Please read the information contained in this notice very carefully.
The American Recovery and Reinvestment Act of 2009 (ARRA) reduces the Cal-COBRA premium in some cases. You are receiving this election notice because you experienced a loss of coverage that occurred during the period that begins withSeptember 1, 2008 and ends with December 31, 2009 and you may be eligible for thetemporary premium reduction for up to nine months. To help determine whether you can get the ARRA premium reduction,you should read this notice and the attached documents carefully. In particular, reference the“Summary of the Cal-COBRA Premium Reduction Provisions under ARRA”with details regarding eligibility, restrictions, and obligations and the “Application for Treatment as an Assistance Eligible Individual.” If you believe you meet the criteria for the premium reduction, complete the “Application for Treatment as an Assistance Eligible Individual”and return it with your completed Election Form.
To elect Cal-COBRA continuation coverage, follow the instructions on the following pages to complete the enclosed Election Form and submit it to us.
If you do not elect Cal-COBRA continuation coverage, your coverage under the Plan will end on [enter date]due to [SENDER checks appropriate box(es)]:
End of employment
Involuntary Voluntary
Divorce or legal separation
Death of employee
Entitlement to Medicare
Reduction in hours of employment
Loss of dependent child status
Depending on your group’s plan, each person (“qualified beneficiary”) in the categories below may be entitled to Cal-COBRA continuation coverage with ARRA premium assistance:
- Employee or former employee
- Spouse or former spouse
- Dependent child(ren) covered under the Plan on the day before the involuntary termination of employment (and any new dependents born, adopted, or placed for adoption between the date coverage was lost and February 17, 2009).
If elected, Cal-COBRA continuation coverage will begin on [enter date] and can last until [enter date]. Cal-COBRA continuation coverage will cost: [enter amount each qualified beneficiary will be required to pay for each option per month of coverage and any other permitted coverage periods]. If you qualify as an “Assistance Eligible Individual” this cost will be [include the amount that the Assistance Eligible Individual is required to pay for each option] for up to nine months. You do not have to send any payment with the Election Form. Important additional information about payment for Cal-COBRA continuation coverage is included in the pages following the Election Form.
If you have any questions about this notice or your rights to Cal-COBRA continuation coverage, you should contact Allied Administrators, Attn: Vicki Poquiz, 633 Battery Street, 2nd Floor, San Francisco, CA94111(877) 472-2669.
Sincerely,
<Sender’s signature block>Cal-COBRA Continuation Coverage Election Form
I (We) hereby apply forCal-COBRA continuation coverage in my former employer’s group health plan arranged through Delta Dentalas indicated below:
NameDate of BirthRelationship to EmployeeSSN (or other identifier)
a. ______
b. ______
c. ______
______
SignatureDate
______
Print NameRelationship to individual(s) listed above
______
______
______
Print AddressTelephone number
Important Information about Your Cal-COBRA Continuation Coverage Rights
Option to Continue Dental Coverage
The California Continuation Benefits Replacement Act (Cal-COBRA) provides continuation coverage for small employer (2-19 employees) dental programs.
In the event of a loss of coverage under your Delta Dental program following the occurrence of certain “Qualifying Events”, you and your dependents are entitled to continue your dental coverage at your expense, if certain conditions are met. The length of time during which you may continue your coverage depends upon the Qualifying Event.
Qualifying Events
Qualifying Events are:
1. / Member Election / 36 Months’ Coverage* / The termination or reduction of hours of the covered employee’s employment, except that termination for gross misconduct does not constitute a qualifying event;2. / Dependent Election / 36 Months’ Coverage / The death of the covered employee;
3. / Dependent Election / 36 Months’ Coverage / The divorce or legal separation of the covered employee from the covered employee’s spouse;
4. / Dependent Election / 36 Months’ Coverage / The loss of dependent status be a dependent enrolled in the plan;
5. / Dependent Election / 36 Months’ Coverage / With respect to a dependent only, the covered employee’s entitlement to coverage under Medicare.
*If the enrollee or dependent enrollee was disabled at any time during the first 60 days of this continued coverage, the coverage may be continued for a total of 29 months, provided that there is a determination under Title II or Title XVI of the Social Security Act that the disabled person was disabled at the time Qualifying Event 1 occurred. Extended coverage under these conditions ends either 36 months after the occurrence of Qualifying Event 1, or on the first of the month that begins more than 31 days after the date of the final determination that the enrollee is no longer disabled, whichever is later.
Please note that Allied Administrators administers Cal-COBRA benefits for your former employer’s Delta Dental program. Therefore, while Delta Dental provides your dental coverage, Allied Administrators will coordinate the collection of premiums and reporting of eligibility. Any Cal-COBRA questions should be directed to Allied Administrators at (877) 472-2669.
How to Continue Dental Coverage
Continued coverage will be the same as you would receive if you were still an enrollee of the dental program. If your employer changes the coverage for active employees, your continued coverage will change as well.
For purposes of this continued coverage, dependent enrollees will include any child born to or placed for adoption with the primary enrollee during continued coverage, if the child is enrolled within 30 days of birth or placement.
Under Cal-COBRA, you will be charged 110% of the premium applicable to active employees in your employer’s group coverage. Please call Allied Administrators should you have any questions in this regard. Delta Dental will deny any dental claims incurred during the election period until you have elected Cal-COBRA and made the initial premium payment. If you did not enclose your initial premium payment with your Election Form, you will have 45 days from your written election of continued coverage to pay the initial premium, which includes the premium for each month since the loss of coverage. Failure to pay the required premium within the 45 days will result in the loss of continued coverage, with no reinstatement.
Payment for subsequent months is due by the 25th of the month PRIOR to the month of coverage. If your payment is more than 30 days late, your Cal-COBRA coverage will be terminated and will not be reinstated.
The American Recovery and Reinvestment Act of 2009 (ARRA) reduces COBRA and Cal-COBRA premium in some cases. The premium reduction is available to certain individuals who experience a qualifying event that is an involuntary termination of employment during the period beginning with September 1, 2008 and ending with December 31, 2009. If you qualify for the premium reduction, you need only pay 35 percent of the Cal-COBRA premium otherwise due to the plan. This premium reduction is available for up to nine months. If your Cal-COBRA continuation coverage lasts for more than nine months, you will have to pay the full amount to continue your Cal-COBRA continuation coverage. See the attached “Summary of the Cal-COBRA Premium Reduction Provisions under ARRA” for more details, restrictions, and obligations as well as the form necessary to establish eligibility.
Termination of Continued Dental Coverage
Your continued coverage will terminate at the end of the month in which any of the following events first occurs:
- The allowable number of consecutive months of continued coverage is reached;
- You fail to pay the required premium in a timely manner;
- Eligibility requirements for this continuation coverage no longer apply to you;
- The employer ceases to provide any group dental program to its employees.
Eligibility Requirements
The continuation coverage is not available to the following individuals:
- Individuals who are entitled or become entitled to coverage pursuant to Medicare;
- Individuals who are covered or become covered under another group benefit plan (other than a group conversion option plan that provides coverage for individuals) that does not impose any exclusion or limitation with respect to any preexisting condition of the individual (other than a preexisting condition limitation or exclusion that does not apply to or is satisfied by the enrollee pursuant to applicable law);
- Individuals who are covered, become covered, or could become covered pursuant to federal COBRA laws;
- Enrollees who fail to meet the requirements regarding notification of a Qualifying Event or the election of continuation coverage within the specified time limits;
- Enrollees who fail to submit the correct premium amount in accordance with the terms and conditions of the plan contract.
Termination of the Employer’s Group Dental Contract
If the group dental contract between your employer and Delta Dental terminates prior to the time that your continuation coverage would otherwise terminate, you (or your eligible dependents) may elect continuation coverage under your employer’s subsequent dental plan, if any. The continuation coverage shall be provided only for the balance of the period that you (or your eligible dependents) would have remained covered under the Delta Dental program had such program with your employer not been terminated. The continuation coverage shall terminate if you fail to comply with the requirements pertaining to enrollment in, and payment of premiums to, the new group benefit plan within 30 days of receiving notice of the termination of the Delta Dental program.
Open Enrollment Change of Coverage
You or your eligible dependents may elect to change your continuation coverage during any employer open enrollment period, if the employer has contracted with another plan to provider coverage to its active employees. The continuation coverage under the other plan shall be provided only for the balance of the period that you (or your eligible dependents) would have remained covered under the Delta Dental program.
Summary of the Cal-COBRA Premium
Reduction Provisions under ARRA
President Obama signed the American Recovery and Reinvestment Act (ARRA) on February 17, 2009. The law gives “Assistance Eligible Individuals” the right to pay reduced Cal-COBRA premiums for periods of coverage beginning on or after February 17, 2009 and can last up to 9 months.
To be considered an “Assistance Eligible Individual” and get reduced premiums you:
MUST be eligible forcontinuation coverage at any time during the period from September 1, 2008 through December 31, 2009 and elect the coverage;
MUST have a continuation coverage election opportunity related to an involuntary termination of employment that occurred at some time fromSeptember 1, 2008through December 31, 2009;
MUST NOT be eligible for Medicare; AND
MUST NOT be eligible for coverage under any other group health plan, such as a plan sponsored by a successor employer or a spouse’s employer.
Individuals who experienced a qualifying event as the result of an involuntary termination of employment at any time from September 1, 2008 through February 16, 2009 and were offered, but did not elect, continuation coverage OR who elected continuation coverage and subsequently discontinuedit may have the right to an additional 60-day election period.
IMPORTANT
◊If, after you elect Cal-COBRA and while you are paying the reduced premium, you become eligible for other group health plan coverage or Medicare you MUST notify the plan in writing. If you do not, you may be subject to a tax penalty.
◊Electing the premium reduction disqualifies you for the Health Coverage Tax Credit. If you are eligible for the Health Coverage Tax Credit, which could be more valuable than the premium reduction, you will have received a notification from the IRS.
◊The amount of the premium reduction is recaptured for certain high income individuals. If the amount you earn for the year is more than $125,000 (or $250,000 for married couples filing a joint federal income tax return) all or part of the premium reduction may be recaptured by an increase in your income tax liability for the year. If you think that your income may exceed the amounts above, you may wish to consider waiving your right to the premium reduction. For more information, consult your tax preparer or visit the IRS webpage on ARRA at
For general information regarding your plan’s Cal-COBRA coverage you can contact Allied Administrators, Attn: Vicki Poquiz, 633 Battery Street, 2nd Floor, San Francisco, CA94111(877) 472-2669. For specific information related to your plan’s administration of the ARRA Premium Reduction or to notify the plan of your ineligibility to continue paying reduced premiums, contact Allied Administrators, Attn: Vicki Poquiz, 633 Battery Street, 2nd Floor, San Francisco, CA94111(877) 472-2669 and/or your former employer.
If you are denied treatment as an “Assistance Eligible Individual” you may have the right to have the denial reviewed. For more information regarding reviews or for general information about the ARRA Premium Reduction go to:
call 1-866-444-EBSA (3272)
To apply for ARRA Premium Reduction, complete this form and return it to us along with your Election Form.
You may also send this form in separately. If you choose to do so, send the completed “Request for Treatment as an Assistance Eligible Individual”to Allied Administrators, Attn: Vicki Poquiz, 633 Battery Street, 2nd Floor, San Francisco, CA94111(877) 472-2669.
You may also want to read the important information about your rights included in the “Summary of the COBRA Premium Reduction Provisions Under ARRA.”
Employer’sName: / REQUEST FOR TREATMENT AS AN ASSISTANCE ELIGIBLE INDIVIDUAL / Allied Administrators, Attn: Vicki Poquiz, 633 Battery Street, 2nd Floor, San Francisco, CA94111(877) 472-2669
PERSONAL INFORMATION
Name and mailing address of employee (list any dependents on the back of this form) / Telephone numberE-mail address (optional)
To qualify, you must be able to check ‘Yes’ for all statements.*
1. The loss of employment was involuntary. / Yes No2. The loss of employment occurred at some point on or after September 1, 2008 and on or before December 31, 2009. / Yes No
3. I elected (or am electing) Cal-COBRA continuation coverage.* / Yes No
4. I am NOT eligible for other group health plan coverage (or I was not eligible for other group health plan coverage during the period for which I am claiming a reduced premium). / Yes No
5. I am NOT eligible for Medicare (or I was not eligible for Medicare during the period for which I am claiming a reduced premium). / Yes No
*If you checked NO for statement 3, you may still be eligible. See below for more information.
*ADDITIONAL ELECTION PERIOD*
If your Cal-COBRA continuation coverage relates to an involuntary loss of employment from September 1, 2008 through February 16, 2009 and you were eligible for, but did not elect, Cal-COBRA continuation coverage OR you elected but subsequently discontinuedCal-COBRA, you may have the right to an additional 60-day election period. You should receive a new election notice with an Election Form which you MUST complete and return. If you believe you should have received this additional notice but have not, contactAllied Administrators, Attn: Vicki Poquiz, 633 Battery Street, 2nd Floor, San Francisco, CA94111(877) 472-2669.
I make an election to exercise my right to the ARRA Premium Reduction. To the best of my knowledge and belief all of the answers I have provided on this form are true and correct.
Signature ______Date ______
Type or print name ______Relationship to employee ______
FOR EMPLOYER OR PLAN USE ONLY
This application is: Approved Denied Approved for some/denied for others (explain in #4 below)
Specify reason below and then return a copy of this form to the applicant.
REASON FOR DENIAL OF TREATMENT AS AN ASSISTANCE ELIGIBLE INDIVIDUAL
1. Loss of employment was voluntary. /
2. The involuntary loss did not occur between September 1, 2008 and December 31, 2009. /
3. Individual did not elect Cal-COBRA coverage.* /
4. Other (please explain) /
*If you checked number 3, was individual eligible for, and given, the Additional Election Period described above?
Signature of employer, plan administrator, or other party responsible for Cal-COBRA administration for the Plan
______Date ______
Type or print name ______
Telephone number ______E-mail address ______
DEPENDENT INFORMATION (Parent or guardian should sign for minor children.)