wageworks cobra by dkkauwe

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									PREMIUM COMPUTATION FORM January20,2009 Whole FoodsMarket 550 Bowie Street Austin, TX78703

Principal Qualifi ed Beneficiary: Mr. Daniel K Kauwe The Health Benefits Continuation Plan requires you to pay premiums according to the scheduleshown below. The premium fur the first partial month, if applicable,has been calculatedfor the iemaining numberof days in the month the Qualifuing Event occurs.

Form. Subsequentoremiumsare due on the first dav of eachmonth_ Your Qualifuing Event Date: l/5/2009 Your Last Enrollment Date: 4/112009 PlanDescription CignaDMO Flexible SpendingAccount UHC EnhancedPPO Plan B United Health CarePWA3 Vision Service Plan Total Monthly Premium:
Coverage Level


Employee Employee Employee Employee Employee

$19.85 s254.99 $186.67 $129.6s $9.28 $600.44

Premium Amount Due if Enrollment tr'orm Signed And ReceivedIn Our Office: 212812009 Amount Due if Enrollment X'orm Signed And ReceivedIn Our Office: 3l3ll200g Amount Due if Enrollment Form Signed 8 y ....................:4 t3 0 t2 0 0 9 Amount Due if Enrollment Form Signed 8y....................: 5/31/2009


$1,412.37 $1,883.16

Premiumsmust be paid to WageWorks,Inc. by check or money order. pLEASE DO NOT SEND CASH.

coverageif a secondqualifoing eventoccursduring the first 18 monthsof continuationcoverage. The maximum qualifoingeventoccursis 36 months. Suchsecond amountof continuation coverage available when a second qualifyingeventsincludethe deathofa covered employee, divorceor separation from the covered employee, a or dependent child'sceasing be eligiblefor coverage a dependent to as underthe Plan. You mustnotif, WAGEWORKS, INC. COBRA ADMINISTRATION within 60 daysafter a secondqualiffing eventoccurs. How can you electcontinuation coverage? Eachqualifiedbeneficiary listedon pageone ofthis noticehasan independent right to electcontinuation coverage. For example,both the employeeand the employee's spouse may elect continuationcoverage, only or one of them. Parents may electto continue coverage behalfof their dependent on childrenonly. A qualified beneficiarymust elect coverageby the datespecifiedon the Election Form. Failure to do so will result in loss of the right to elect continuationcoverageunderthe Plan. A qualified beneficiarymay changea prior rejectionof continuation coverage time until that date. any In consideringwhetherto elect continuationcoverage, you shouldtake into accountthat a failure to continueyour group health coverage will affect your future rights underfederallaw. First, you can lose the right to avoid having pre-existing conditionexclusions appliedto you by othergrouphealthplansifyou havemorethana 63-daygap in healthcoverage, electionof continuation and you will coverage may help you not havesucha gap. Second, policies that do not imposesuchpre-existing lose the guaranteed right to purchaseindividual health insurance conditionexclusions you do not get continuation if coverage the maximumtime available you. Finally,you for to shouldtake into accountthat you have specialenrollmentrights under federal law. You havethe right to request specialenrollmentin anothergroup healthplan for which you are otherwiseeligible (such as a plan sponsored by your spouse's employer) within 30 daysafteryour grouphealthcoverage endsbecause ofthe qualifyingevent listed above. You will also have the samespecialenrollmentright at the end of the continuationcoverageif you get continuationcoveragefor the maximum time availableto you. What if I am elisible for trade adjustment assistance? The Trade Act of 2002 createda new tax credit for certain individualswho becomeeligible for trade adjustment (eligibleindividuals).Underthe new tax provisions, assistance eligibleindividuals can eithertakea tax creditor get advance payment 650/o premiums paid for qualifiedhealthinsurance, of of includingcontinuation coverage.If you have questions aboutthesenew tax provisions,you may call the Health CareTax Credit CustomerContact Centertoll free at l-866-628-4282. TTD/TTY callersmay call toll free at 1-866-626-4282.More information aboutthe TradeAct is alsoavailable www.doleta.sov/tradeact/2002act at index.asp. When and how must nayment for continuation coveragebe made? First payment continuationcoverage for Ifyou elect continuationcoverage, you do not haveto sendany paymentfor continuationcoveragewith the Election Form. However,you must make your first paymentfor continuationcoveragewithin 45 days after the dateof your election.(This is the datethe ElectionNotice is post-marked, mailed.) If you do not rnakeyour first if paymentfor continuationcoverage within that 45 days,you will lose all continuationcoveragerights underthe Plan. Your first paymentmust cover the cost of the continuationcoveragefrom the time your coverageunderthe Plan would haveotherwise terminated to the time you makethe first payment.You areresponsible makingsure up for that the amountof your first payment enough coverthis entireperiod. You may contactWAGEWORKS, is to INC. COBRA ADMINISTRATION to confirm the correctamountof your first payment. Your first paymentfor continuationcoverageshouldbe sentto: WAGEWORKS, INC. COBRA ADMINISTRATION 1155ReliableParkway Chicago, 60686 IL Periodic payments continuationcoverage for After you make your first paymentfor continuationcoverage, you will be requiredto pay for continuation

WholeFoods Markel 550BowieStreet Austin, 78703 TX January 20,2009
Mr. Daniel K Kauwe 933 BegoniaAve CostaMesa,CA92626 DearMr. Kauwe: This notice contains important information about your right to continue your health care coveragein the Whole FoodsMarket Group Health Plan (the plan). Pleaseread the information contained in this notice very carefully. This notice provides important information concemingyour rights and what you have to do to continueyour health care coverageunder the plan for you and your covered dependents, any, as defined on the enclosedFamily Member Enrollment Form. If you have anv if questionsconcemingthe information in this notice or your rights to coverage, you shouldcontact WAGEWORKS, INC. COBRA ADMIMSTRATION I 155ReliableParkway Chicago, 60686 IL r-877-s02-6272 If you do not elect to continue your health care coverageby completing the enclosed"Enrollment Form" and returning it to us, your coverageunderthe Plan will not be in force as of 211/2009 to: due LEAVE OF ABSENCE Each of the following qualified beneficiariesare being offered continuationunderthe plan: Mr. DanielKauwe Becauseof the above event that will end your coverageunder the Plan, you are entitled to continue your health care coverage up to 18 MONTHS. If you elect to continueyour coverage for underthe Plan, your continuation coverage will beginon 211/2009 can lastuntil Blll2010and If you had a Personal WellnessAccount (PWA) upon termination, your PWA/Consumer Account Card will be turned off at termination. However, your PWA funds will remain active and availablefor six (6) months from the date of termination or statuschange. To receive reimbursement you must submit a manual claim form and claim forms are availableby calling UHC at l-877-263-6698or logging onto www.myuhc.com. you will have 90 days after your coverageends to file claims for the eligible expensesincurred during your covered period. COBRA continuationfor PWA should only be electedif you have a remaining PWA balanci upon termination and want to continue to accessfunds beyond the 6 months from date of termination. You will not receive additional pWA funds. If you are electing to continue coverageand are not/were not the primary policy holder, your deductiblewill be restarted. This applies to spousesor dependents the policy holder. No prior claims will be applied to the of coverage you electto continue. If you had life insurance coverage, your plan may be availablefor conversion an individual policy within 3l to days of coverageend. For any information on how to apply for the conversion,pleasecontact Whole foods at 512-542-0457. ..Enrollment Form,' and IMPORTANT - To elect continuation coverage, you MUST completethe enclosed return it to us. You may mail it to the addressshown on the Enrollment tr'orm.The completedEnrollment Form must be post-markedby 4/1i2009. you do not submit a completedEnrollment Form tly this date,you If will loseyour right to electcontinuation coverage. Notice under Califomia COBRA

NOTICE TO TERMINATING EMPLOYEES premiumsfor certainpersons will pay the private health insurance The California Departmentof Health Services who are losing employmentand have a high cost medical condition. In order to qualify for the Health Insurance PremiumPayment(HIPP) program,you must meet ALL of the following conditions: l. 2. 3. You must currentlybe on MediCal. of Your MediCal share costmustbe $200OR LESS. monthly costof your healthcaremust be at medicalcondition. The average You musthavean expensive that amount leasttwice asmuch as the monthly insurancepremiums. If you have a MediCal shareofcost, from your monthly health carecoststo determineif paying the premiumsis cost will be subtracted effective. policy, or a COBRA conversion policy, COBRA continuation You musthavea currenthealthinsurance policy in effect or availableat the time of application. your high costmedicalcondition. policy MUST NOT exclude Your healthinsurance Your applicationmust be made in time for the Stateto processand startpayment. policy MUST NOT be issued throughthe California Major Risk MedicalInsurance Your healthinsurance Board. You MUST NOT be enrolledin a MediCal relatedprepaidhealthplan,the SanMateo CountyHealthPlan, Health Plan, or a County Medical the SantaBarbaraCounty Health Initiative, the SolanoPartnership (CMSP). Program Services Your healthinsurancepolicy MUST NOT be provided by an absentparent. TO ENROLL IN HIPP OR TO INQUIRE ABOUT REQUIREMENTS, CALL THIS TOLL FREE NUMBER 1and with the HIPP unit). to instructions be connected follow the automated l-800-952-5294 DISABLED BY HIV/AIDS FOR PERSONS unableto work (CARE) Act of 1990,persons Emergency AIDS Resources Underthe Ryan White Comprehensive may qualifu for the of because disabilitydueto HIV/AIDS andwho arelosingtheir privatehealthinsurance Health InsuranceContinuationProgram(CARE/HIPP) for up to 12 monthsprovided they: (SDI), or other (SSI), State DisabilityInsurance Disability Insurance Have appliedfor SocialSecurity 'disabilityprograms: Are currently coveredby a healthinsuranceplan, which includesoutpatientprescriptiondrug coverageand (individual,family, or groupplans); services HIV treatment Program(ADAP); 3... Are not currentlyon the AIDS Drug Assistance of 4. \ Have a total monthlyincomebelow 250 percent the currentfederalpovertylevel and; \Will S. be elieiblefor the MediCalHIPP Prosramwithin 12 months. l. \ call: FOR ADDITIONAL INFORMATION ON CARE/HIPP,please CaliforniaAIDS Hotline or JQouthern CalifomiaAIDS Hotline Northern l -8 0 0 -3 6 7 -2 4 3 7 (E n g l i sh/S pani sh)' ' l -800-922-2437(E ngl i sh) 8 1-800 -922-243 (Multilanguage)

4. 5. 6. 7. 8.


coveragefor eachsubsequent month of coverage. Under the Plan, theseperiodic paymentsfor continuation coverageare due on the first day of eachmonth. If you make a periodic paymenton or beforeits due date,your coverageunderthe Plan will continuefor that coverageperiod without any break. Periodic paymentsfor continuationcoverage shouldbe sentto: WAGEWORKS, INC. COBRA ADMINISTRATION 1155ReliableParkway Chicago, 60686 IL Grace periods for periodic payments Although periodic paymentsare due on the datesshown above,you will be given a graceperiod of 30 daysto make eachperiodic payment. Your continuationcoverage will be provided for eachcoverageperiod as long as paymentfor that coverage period is madebeforethe end of the graceperiod for that payment. However, if you pay a periodic paymentlater than its due datebut during its graceperiod, your coverageunderthe Plan will be (going back to the due date)when the periodic suspended ofthe due dateand then retroactivelyreinstated as paymentis made. This meansthat anyclaim you submit for benefrtswhile your coverageis suspended may be deniedand may haveto be resubmittedonceyour coverage reinstated. is If you fail to make a periodic paymentbeforethe end of the graceperiod for that payment,you will lose all rights to continuationcoverage underthe Plan. Can I voluntarilv terminate coveraseafter I've elected? Yes, proactively. In order to voluntarily drop benefits,you must submit a signedletter PRIOR to the dateyou postmarked wish to terminatebenefits. Terminationrequests after the requested terminationdatewill not be honored. The next availableterminationdatewill be the next I't of the month. For instance,if you wish to terminatebenefitsJune I , the voluntarytermination letter must be postmarked or beforeMay 3 l. If the post on mark is after June 1 (but beforeJuly I ), the next availableterminationdatewill be July I . For more information This notice doesnot fully describecontinuationcoverage other rights underthe Plan. More information about or continuationcoverageand your rights underthe Plan is availablein your summaryplan descriptionor from the Plan Administrator. You can get a copy of your summaryplan descriptionfrom: WholeFoodsMarket 550 Bowie Street Austin,TX 78703 For more iriformationaboutyour rights underERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans,contactthe U.S. Departmentof Labor's (EBSA) in your areaor visit the EBSA websiteat www.dol.gov/ebsa. Employee BenefitsSecurity Administration Keen Your Plan Informedof AddressChanses In order to protect your family's rights, you shouldkeepthe Plan Administrator informed of any changes the in address family members.You shouldalsokeepa copy,for your records, any noticesyou sentto the Plan of of Administrator. WageWorks, Inc. I155 ReliableParkway(NO OVERNIGHT MAIL) Chicago, 60686 IL WageWorks,Inc. 1940Springer Drive (Overnight mail ONLY) Lombard,lL 60148

WAGEWORKS, INC. COBRA ADMINISTRATION parkway 1155Reliable Chicago,IL 60686 (877)s02-6272 Enroflment Formscanbe faxed to: 630_629_5374

What is continuation coverage? Federallaw requiresthat most group healthplans (including this Plan) give employees and their families the opportunityto continuetheir healthcarecoveragewhen there is a "qualifiing event" that would result in a loss of coverageunder an employer'splan. Dependingon the type of qualifying event,"qualified beneficiaries"can include the employeecoveredunderthe group health plan, a coveredemployee's spouse, and dependent children of the coveredemployee. Continuationcoverageis the samecoverage that the Plan gives to other participantsofbeneficiaries underthe Plan who arenot receivingcontinuationcoverage. Each qualified beneficiarywho electscontinuationcoveragewill havethe samerights underthe Plan as other participantsor beneficiariescoveredunderthe Plan. The persons listedon pageoneofthis noticehavebeenidentifiedby the Plan as qualifiedbeneficiaries entitledto elect continuationcoverage. Specific information describingcontinuationcoveragecan be found in the Plan'ssummary plan description (SPD),which canbe obtained from Whole FoodsMarket 550 Bowie Street Austin, TX 78703 How long will continuationcoveraselast? In the caseof a loss of coveragedue to end of employmentor reductionin hours of employment,coveragemay be continued up to 18 months. In the caseoflossesofcoveragedueto an employee's for death, divorceor legal separation, a dependent or child ceasing be a dependent to underthe termsofthe plan,coverage may be continued for up to 36 months. Pageone of this notice showsthe maximum period of continuationcoverageavailableto the listedqualified beneficiaries. Continuationcoverage will be terminatedbefore the end of the maximum period if any requiredpremium is not paid on time, if a qualified beneficiarybecomescoveredunder anothergroup healthplan that doesnot imposeany pre-existing conditionexclusionfor a pre-existing conditionof the qualifiedbeneficiary, a covered if employee enrollsin Medicare, if the employerceases provideany grouphealthplan for it employees. or to Continuation coveragemay also be terminatedfor any reasonthe Plan would terminatecoverage a participantor beneficiary of (suchas fraud). not receivingcontinuation coverage How can you extendthe length ofcontinuation coverage? If you elect continuationcoverage, extensionof the maximum period of 18 monthsof coveragemay be an qualifyingeventoccurs.You mustnotifi available a qualifiedbeneficiary disabled a second if is or WAGEWORKS, INC. COBRA ADMINISTRATION of a disability or a secondqualifying event in order to extendthe period of continuationcoverage. Failure to provide notice of a disability or secondqualifling event may affect the right to extendthe period of continuationcoverage. Disability An I l-month extension coverage of may be available any of the qualifiedbeneficiaries disabled.The Social if is (SSA) mustdetermine SecurityAdministration that the qualifiedbeneficiary was disabled sometime duringthe at first 60 daysof continuationcoverage, and you must notify WAGEWORKS, INC. COBRA ADMINISTRATION of that fact within 60 daysof the SSA'sdetermination beforethe end of the first l8 monthsof continuation and coverage.All ofthe qualifiedbeneficiaries listedon pageoneofthis noticewho haveelected continuation coverage will be entitledto the 1I -monthdisabilityextension one of them qualifies.If the qualifiedbeneficiary if you mustnotify WAGEWORKS,INC. COBRA is determined SSAto no longerbe disabled, by ADMINISTRATION of that fact within 30 days of SSA'sdetermination. SecondQualifuing Event An 18-month extension coverage of will be available spouses dependent to and childrenwho electcontinuation


COBRA Administration I155 Reliable Parkway ChicagoIL 60686

1t20/2009 DearWholeFoodsCOBRA Participant: WageWorks, Inc. is pleased inform you that accessing to your COBRA Accountonlineis just a click away! You will be ableto verify the status your enrollment, of confirmthe plansyou areenrolledin, view your covered dependents verify payments and received.You will alsobe ableto set answers commonlyaskedcoBRA questions clicking on the Help tab. to by Accessing your account informationis easy. Justgo to http://www.waqeworks.com/and click on "Register now" nextto "First time user?" You will be asked enterthe followins information: to First Name LastName Date of Birth (mm/dd) Home Zip Code ID Code(last4 digits)- This will be the last4 digits of your socialsecurity number Enterthe characters displayed the "box below" in Thenclick the NEXT button You will be askedto provide your contactinformation as we may needto contactyou for Customer Service.Please verify the address haveon file for you is correctto ensure we you receiveour mailings. Lastly,you will needto establish your UserID andPassword future for visitsto our site. Oncecompleted, are on your way to accessing you your account! As always,our Dedicated COBRA Customer Service Unit is available you Mondaythrough to Friday,7:00a.m.to 5:00p.m.centralandcanbe reached dialing1.g77.502.6272. by Sincerely, WageWorks,Inc. COBRA Administrator for Whole Foods Market

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