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Sample COBRA Notice

If you are an employee of the University of Arizona covered by the State of Arizona Benefit Options, you have the right to choose continuation coverage if you lose your group health coverage because of a reduction in your hours of employment or the termination of your employment (for reasons other than gross misconduct on your part).

If you are a spouse of an employee covered by the Plan, you have the right to choose continuation coverage for yourself if you lose group health coverage under the Plan for any of the following reasons:

1. The death of your spouse;
2. A termination of your spouse’s employment for any reason other than gross misconduct;
3. Spouse’s reduction in hours of employment;
4. Spouse’s change to a non-benefits eligible position;
5. Divorce or legal separation from your spouse; or,
6. Your spouse becomes entitled to Medicare.

If you are a dependent child of an employee covered by the Plan, you have the right to continuation coverage if group health coverage under the Plan is lost for any of the following reasons:

1. The death of the parent;
2. The termination of the parent’s employment for any reason other than gross misconduct;
3. Parent’s reduction in hours of employment;
4. Parent’s change to a non-benefits eligible position;
5. Parent’s divorce or legal separation;
6. The covered parent becomes entitled to Medicare; or
7. You cease to be a "depended child" under the Plan, due to age and/or student status change.

Under the law, the employee or a family member must inform the University of a divorce, legal separation, or a child losing dependent status under the Plan within 60 days of such event. If notice is not received by Benefits Services within that 60-day period, the dependent will not be entitled to choose continuation coverage.

When Benefits Services is notified that one of these events has happened, you will in turn be notified of your right to choose continuation coverage. Under the law, you have 60 days from the later of the date you would lose coverage because of one of the events described above or the date you receive your COBRA Notice, to inform Benefits Services that you wish to elect continuation coverage.

If you do not choose continuation coverage, your group health insurance will end as of the date coverage would cease as a result of the qualifying event.

If you choose continuation coverage, the University is required to give you coverage which, as of the time coverage is being provided, is identical to the coverage provided under the Plan to similarly situated employees or family members. If coverage under the Plan is changed for active employees, the same changes will be provided to individuals purchasing continuation coverage. You will be provided with notification of any plan changes. In the event that a child is born to you or placed in your home for adoption during your period of COBRA coverage, the child shall be a qualified beneficiary and may be covered immediately so long as you have informed the appropriate carrier (s) within 30 days.

The law requires that you and your covered dependents be given the opportunity to maintain continuation coverage for 36 months unless you lost group health coverage because of a termination of employment, change to a non-eligible position, or reduction in work hours. In the case of termination of employment, change to a non-benefits eligible position, or reduction of hours, the required continuation period is 18 months.

In the case of termination of employment while you were totally disabled, or if you become disabled within 60 days of your termination of employment as determined under Title II or Title XVI of the Social Security Act, the required continuation coverage is extended to 29 months. You must also notify the Plan Administrator within 30 days of any final determination by Social Security that you are no loner disabled. In the case of your becoming entitled to Medicare, your eligible dependents may continue coverage for 36 months from the date you first lost coverage. If, during the initial period, another event takes place that would also entitle a dependent spouse or child (other than a spouse or child who became covered after the continuation coverage became effective) to his or her own continuation coverage, the continuation coverage may be extended. However, in no case will any period of continuation coverage be more than 36 months.

The law also provides that your continuation coverage may be discontinued for any of the following reasons:

1. The University no longer provides group health coverage to its employees;
2. The premium for your continuation coverage is not paid in a timely fashion;
3. You have been covered under another group health plan which either contains no pre-existing conditions limitations or contains such a limitation which you have satisfied with proof of credible coverage;
4. You become entitled to Medicare; or,
5. In the case of the 11 month extended coverage due to disability, that coverage will be terminated as of the first month that starts at least 30 days after a final determination under the Social Security Act, that you are no longer disabled.

You do not have to prove evidence of insurability to choose continuation coverage. However, under the law, you will be required to pay the group rate premium (both employee and employer portion) plus a 2% administration fee for your continuation coverage. You will have a grace period of 45 days from the date of your election of COBRA coverage to pay any retroactive premium for the period from the date continuation coverage starts until the date you choose continuation coverage; and you will have a grace period of 30 days to pay any subsequent premiums.