Maine Continuation Coverage Election Notice [Mini-COBRA] (For use where coverage is subject to State continuation requirements during the period that begins with September 1, 2008 and ends with December 31, 2009.) [Enter date of notice] Dear: [Identify the qualified beneficiary(ies), by name or status] This notice contains important information about your right to continue your health care coverage in the [enter name of group health plan] (the Plan). If you do not qualify for COBRA coverage under federal law, you may still qualify for Maine’s continuation coverage, which is sometimes referred to as “mini-COBRA.” Under Maine’s continuation of coverage law,1 employees who work for employers with fewer than 20 employees have a limited right to continued enrollment in their health insurance plan. Continued enrollment is available if you lost your health insurance coverage as a result of being temporarily laid off or if you lost employment because of a work related injury or disease that would be covered under the workers’ compensation laws. Generally to qualify: you had to work for the company for at least six months, cannot be eligible for Medicare, and cannot be covered or eligible for coverage by any other plan or program. Please read the information in this notice very carefully. The American Recovery and Reinvestment Act of 2009 (ARRA) reduces the continuation coverage premium in some cases. If you lost coverage during the period that begins with September 1, 2008 and ends with December 31, 2009 because of a temporary layoff or because of a work related injury or disease, you may be eligible for the temporary premium reduction for up to nine months. If your Maine continuation coverage lasts for more than nine months, you will have to pay the full amount to continue your Maine continuation coverage after that time. If you qualify for the premium reduction, you need only pay us at most 35 percent of the continuation coverage premium that would otherwise be due. See the attached “Summary of the Continuation Coverage Premium Reduction Provisions under ARRA” for more details, restrictions, and obligations, as well as the form necessary to establish eligibility. To help determine whether you can get the ARRA premium reduction, you should read this notice and the attached documents carefully. 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 Maine Continuation Coverage Election Form. To enroll in Maine continuation coverage, follow the instructions on the following pages, complete the enclosed Maine Continuation Coverage Election Form, and submit it to us together with your initial payment within 31 days of the termination of coverage under your health plan. If you do not choose to enroll in continuation coverage, your coverage under the Plan will end on [enter date]. The employee may elect to enroll the persons checked below in Maine continuation coverage, which will continue group health care coverage under the Plan for up to 12 months.
Employee Spouse
1
24-A M.R.S.A. § 2809-A(11)
Dependent child(ren)
At the employee’s option, your Maine continuation coverage may cover only the employee, only the other family members who are checked above, or the employee and the family members. Family members are checked if they were covered for at least 3 months under the group policy, or if they were not covered because they were not yet eligible for coverage at that time. If you believe there has been a mistake and that you have additional family members who are eligible for coverage, please contact us. If chosen, Maine continuation coverage will begin on [enter date of temporary layoff or loss of employment due to work related injury or disease] and can last for 12 months. However, coverage may be terminated earlier if: (1) The member or employee fails to make timely payment of a required premium amount; (2) The member or employee becomes eligible for coverage under another group policy; or (3) The Workers' Compensation Board determines that the injury or disease that entitles the employee to continue coverage under this section is not compensable under Title 39-A. 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 can be reduced to [include the amount that is 35 percent of the amount above for each option] for up to nine months. Maine law provides that the member or employee has 31 days from the termination of coverage in which to elect and make the initial payment for Maine continuation coverage. Important additional information about payment for continuation coverage is included with the Election Form. Maine continuation coverage is the same coverage that the Plan gives to other participants or beneficiaries under the Plan who are not receiving continuation coverage. Each qualified beneficiary who elects continuation coverage will have the same rights under the Plan as other participants or beneficiaries covered under the Plan, including [add if applicable: open enrollment and] special enrollment rights. In considering whether to enroll in continuation coverage, you should take into account that a failure to continue health coverage will affect your future rights under state and federal law. First, you can lose the right to avoid having preexisting condition exclusions applied to you by other group health plans if you have a 90-day gap in health coverage, and continuation coverage may help prevent such a gap. If your plan is not subject to Maine law, a gap of coverage as short as 63 days could subject you to preexisting condition exclusions. Further, if you do not maintain group coverage and move to another state you might not qualify for an individual policy in that state. Finally, you should take into account that you have special enrollment rights under state and federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within 30 days after your group health coverage ends because of the qualifying event. You will also have the same special enrollment right at the end of continuation coverage if you get continuation coverage for the maximum time available to you. Keep Us Informed of Address Changes In order to protect your and your family’s rights, you should keep [enter name and contact information for the appropriate party responsible for continuation coverage administration under the Plan] informed of any changes in your address and the addresses of family members. You should also keep a copy, for your records, of any notices you send to [enter the name of the party responsible for continuation coverage administration under the Plan].
For more information This notice does not fully describe continuation coverage or other rights with respect to your coverage. For additional information and answers to any questions concerning the information in this notice and your rights to coverage you should contact [enter name of party responsible for continuation coverage administration for the Plan, with telephone number and address]. For more information about your rights under state law, contact the Maine Bureau of Insurance toll-free at 1-800-300-5000. Trade Adjustment Assistance [IF APPLICABLE] [If employees might be eligible for trade adjustment assistance, the following information must be added: The Trade Act of 2002 created a tax credit for certain individuals who become eligible for trade adjustment assistance and for certain retired employees who are receiving pension payments from the Pension Benefit Guaranty Corporation (PBGC). Under the tax provisions, eligible individuals can either take a tax credit or get advance payment of 65% of premiums paid for qualified health insurance, including continuation coverage. ARRA made several amendments to these provisions, including an increase in the amount of the credit to 80% of premiums for coverage before January 1, 2011 and temporary extensions of the maximum period of continuation coverage for recipients of PBGC payments and trade adjustment assistance. Further information on trade adjustment assistance is available from the Maine Department of Labor at http://www.maine.gov/labor/unemployment/specialprograms.html. Information is also available from the U.S. Department of Labor. You may call the Health Coverage Tax Credit Customer Contact Center toll-free at 1-866628-4282. TTD/TTY callers may call toll-free at 1-866-626-4282. More information about the Trade Act is also available at www.doleta.gov/tradeact.]
Summary of the 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 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 have a continuation coverage opportunity because of an involuntary termination of employment that occurred at some time from September 1, 2008 through December 31, 2009; MUST enroll in continuation coverage; 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. If you lost your job at any time from September 1, 2008 through February 16, 2009 and you declined continuation coverage, OR you elected continuation coverage and subsequently discontinued it, you may have the right to an additional 60-day election period. IMPORTANT ◊ If, after you elect COBRA (or Maine continuation coverage) 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 www.irs.gov. For general information regarding your plan’s Maine continuation coverage you can contact [enter name of party responsible for continuation coverage administration for the issuer, with telephone number and address]. For specific information related to your plan’s administration of the ARRA Premium Reduction, or to notify the plan that you are no longer eligible to continue paying reduced premiums, contact [enter name of party responsible for ARRA Premium Reduction administration for the Plan, with telephone number and address]. 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:
www.dol.gov/COBRA or call 1-866-444-EBSA (3272)
To apply for ARRA Premium Reduction, complete this form and return it to: [Enter Name and Address] You may also want to read the important information about your rights included in the “Summary of the COBRA Premium Reduction Provisions Under ARRA.”
REQUEST FOR TREATMENT AS AN ASSISTANCE ELIGIBLE INDIVIDUAL PERSONAL INFORMATION
Name and mailing address of employee (list any dependents on the back of
this form)
[Insert Plan Name]
[Insert Plan Mailing Address]
Telephone number E-mail address (optional)
To qualify, you must be able to check ‘Yes’ for all statements.*
1. The loss of employment was involuntary. 2. The loss of employment occurred at some point on or after September 1, 2008 and on or before December 31, 2009. 3. I elected State continuation or COBRA continuation coverage. 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). 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 Yes No Yes No Yes No Yes No
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 ISSUER 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 continuation coverage. 4. Other (please explain)
Signature of party responsible for continuation coverage administration for the Issuer __________________________________________________ Date Type or print name Telephone number ____________________________
_____________________________________________________________________________ ____________________________ E-mail address ____________________________
DEPENDENT INFORMATION (Parent or guardian should sign for minor children.) Name Date of Birth Relationship to Employee SSN (or other identifier)
a. _________________________________________________________________________
1. I elected (or am electing) Maine continuation or COBRA continuation coverage. 2. I am NOT eligible for other group health plan coverage. 3. I am NOT eligible for Medicare. Yes No Yes No Yes No
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 _________________________
Name
Date of Birth
Relationship to Employee
SSN (or other identifier)
b. _________________________________________________________________________
1. I elected (or am electing) Maine continuation coverage. 2. I am NOT eligible for other group health plan coverage. 3. I am NOT eligible for Medicare. Yes No Yes No Yes No
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 _________________________
Name
Date of Birth
Relationship to Employee
SSN (or other identifier)
c. _________________________________________________________________________
1. I elected (or am electing) Maine continuation coverage. 2. I am NOT eligible for other group health plan coverage. 3. I am NOT eligible for Medicare. Yes No Yes No Yes No
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 _________________________
This form is designed for plans to distribute to Maine continuation qualified beneficiaries who are paying reduced premiums pursuant to ARRA so they can notify the plan if they become eligible for other group health plan coverage or Medicare.
IMPORTANT: Save this form and use it to notify your issuer if you become eligible for other group health plan coverage or Medicare.
Plan Name
Plan Mailing Address
Participant Notification
PERSONAL INFORMATION
Name and mailing address Telephone number
E-mail address (optional)
PREMIUM REDUCTION INELIGIBILITY INFORMATION – Check one
I am eligible for coverage under another group health plan.
If any dependents are also eligible, include their names below.
Insert date you became eligible______________________ I am eligible for Medicare. Insert date you became eligible______________________
IMPORTANT
If you fail to notify your plan of becoming eligible for other group health plan coverage or Medicare AND continue to pay reduced COBRA premiums you could be subject to a fine of 110% of the amount of the premium reduction. Eligibility is determined regardless of whether you take or decline the other coverage. However, eligibility for coverage does not include any time spent in a waiting period.
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
_____________________________________________________________________________
If you are eligible for coverage under another group health plan and that plan covers dependents you must also list their names here:
_________________________________________
_________________________________________
_________________________________________
_________________________________________