Download Date: April 13, 2004 - Stanford Management

Date:
August 12, 2017
From:
LAZ Parking
15 Lewis Street
Hartford, CT 06103
To:
Lisa Gregorio
Hunting Rd.
Needham, MA 02494
All family members should read this notice carefully and retain for future reference. This notice applies to any employee, spouse and/or dependent
child who was covered by the employer’s group health plan and lost coverage due to a qualifying event. Loss of coverage also includes an increase
in the premium due to a qualifying event.
Federal COBRA law allows a temporary extension of group health insurance coverage to qualified beneficiaries when coverage is lost due to the
qualifying event listed below.
YOUR PLAN OPTIONS, MONTHLY RATES, AND DUE DATES ARE:
Plan
Coverage
Option
Anthem
MEDICAL
Family
Guardian
DENTAL
Family
Event
COBRA Coverages and Premiums
Event
Loss of
Must
Date
Coverage
Elect By
Coverage
Expires
Premium
Day Due
End of Employment
8/20/2012
9/1/2012
11/1/2012
3/1/2013
$400.89
1st
End of Employment
8/20/2012
9/1/2012
11/1/2012
3/1/2013
$27.21
1st
An election is deemed to be made on the date the election is sent. If you do not send it before the last date to elect COBRA, you may lose the
opportunity to elect.
COBRA QUALIFIED BENEFICIARIES: Each employee, spouse and dependent child covered under the group health plan the day before the
qualifying event is a qualified beneficiary and has independent election rights under COBRA. This means each qualified beneficiary may elect to
continue coverages that were in place at the time of the qualifying event. COBRA qualified beneficiaries may also be allowed all options that active
employees have under the plan, under the same terms and conditions as the active employees. If, during the COBRA coverage period, a child is born
to or placed for adoption with the covered employee on COBRA, that child will be provided qualified beneficiary status if the child is enrolled on the
plan.
ELECTING COBRA COVERAGE: To elect COBRA, complete the enclosed election form and send it to Wentworth DeAngelis & Kaufman,
Attn: Tammy Davis, 74 Batterson Park Rd, Farmington, CT 06032. Your COBRA election may be required to be made in writing. Generally,
you will be removed form the group health plan during the election period. If COBRA is elected and paid for within the proper time frames, your
coverage will reinstate without interruption from the date of the qualifying event after valid payment is made. If the employer/plan administrator
allows you to sign a waiver regarding your continuation coverage, you may revoke the waiver during the election period. However, any claims
incurred within the waiver period may not be covered. If you elect COBRA, your employer/plan administrator reserves the right to verify your
eligibility and they reserve the right to terminate coverage retroactively if you are not eligible. COBRA may be denied based upon, but not limited to,
termination of employment due to gross misconduct. If a qualified beneficiary is incapacitated, other specific individuals could elect on hi/her behalf
by contacting the employer/plan administrator.
HMO INFORMATION: If you participated in an HMO or walk-in clinic and used the provider’s services during the election period, the employer’s
plan may allow the employer, at the employer’s option, to treat such a use as a constructive election. You would be obligated to pay any applicable
charge for the coverage within 45 days of the constructive election. NO all employers may recognize constructive elections. HMOs may provide
region-specific coverage. For a COBRA qualified beneficiary outside of the region, coverage may be reduced similarly to that of active employees
outside of the region. In certain instances, coverage may be eliminated or provided for emergency service only. If the employer or plan administrator
has a plan that would provide you coverage outside of the HMO region, this plan must be made available to you either on the date of your relocation
or, if later, the first day of the month following your request for this coverage. Please refer to your insurance booklet for specific information.
PREMIUM PAYMENTS: The employer may charge up to 102% of the applicable premium for COBRA. If you elect COBRA, you are allowed 45
days, which begins on the date your election is sent to pay for the premiums retroactive to the loss of coverage date. Checks must be made payable
to LAZ Parking. You are allowed a minimum 30-day grace period on each monthly premium. Federal COBRA law does not require an additional
grace period beyond the end of the 45-day period for payment of the retroactive premium. In some cases, a person may be removed from the plan in
anticipation of a qualifying event (e.g., divorce or legal separation). In such cases, retroactive premiums may only be due to the event date (e.g., date
of divorce or legal separation) rather than the loss of coverage date. The coverage the qualified beneficiary had at the time of the loss of coverage
must be offered under COBRA. The employer/plan administrator is not required to provide coverage from the loss of coverage to the qualifying
event date. Any claims made after your loss of coverage date may be held until you elect COBRA and all premiums are current. Failure to pay ANY
premium will cause your coverage t be retroactively terminated. Premium payments may be made in monthly installments (including the retroactive
payment). In some cases, COBRA premiums may be paid on a pre-tax basis under a Section 125 (cafeteria) plan established by the employer.
Sending premium invoices is not required under COBRA law. It is your responsibility to pay premiums even in the absence of an invoice.
COBRA EXTENSIONS: The 30-month period (for a termination or a reduction of hours) may be extended to a maximum of 36 months if another
qualifying event (death of the employee, divorce or legal separation, employee’s Medicare entitlement or a dependent child ceasing to be a
dependent) occurs during the original 18-month period. You need to notify the employer/plan administrator if you experience a second qualifying
event and would like to extend your COBRA. Connecticut Public Act 10-13 extended the maximum continuation period for certain qualifying events
from 18 months to 30 months. This change applies to individuals who are currently on state or federal COBRA continuation through coverage under
a Connecticut group health insurance policy as well as to individuals covered under a Connecticut group health insurance policy who experience a
qualifying event on May 5, 2010 or later. Please see the attached notice SUPPLEMENT to see if you qualify.
DISABILITY INFORMATION: If any qualified beneficiary is deemed disable by the Social Security Administration (under Title II or XVI of the
Social Security Act) prior to or within the first 60 days of COBRA, all qualified beneficiaries may be eligible to extend their COBRA up to 29
months from the date of the termination or reduction of hours. To receive this COBRA extension, you must notify the employer/plan administrator of
the disability determination before the 18 months expires and within 60 days of the determination letter. If the disabled qualified beneficiary is
deemed no longer disabled, you need to notify the employer/plan administrator within 30 days of that determination. If deemed no longer disabled,
all qualified beneficiaries are no longer eligible for the additional 11 months of COBRA and coverage will end the month that begins 30 days after
the date of the final determination. Up to 150% of the applicable premium could be charged for this extension of COBRA from the 19 th through the
29th month, if the disabled qualified beneficiary is part of the extension.
REASONS COBRA COULD TERMINATE EARLY:
1.
2.
3.
4.
5.
The employer no longer provides any group health coverage to any employee.
Any COBRA premium is no paid by the grace date.
After the date you elect COBRA, you become covered under another group health plan that;

Does not contain any exclusion or limitation with respect to any pre-existing condition that applies to you.

Has pre-existing condition limitation that do not apply to you.

Has pre-existing condition clauses that apply to you, which you have satisfied
After the date you elect COBRA, you become entitled to Medicare (actually enrolled, not just eligible).
If the Qualified Beneficiary is no longer deemed disabled by Social Security, coverage will terminate the first of the month that is more
than 30 days after the date of the final determination.
COBRA continuation coverage may be retroactively terminated for cause (e.g., fraudulent activity) on the same basis that the plan terminates the
coverage of a similarly situated active employee for cause. Health FSAs (Section 125 or cafeteria plans) may have a separate, earlier expiration date.
INDIVIDUAL CONVERSION OPTION: You may be eligible to elect an individual conversion option if your plan has such an option. Conversion
coverage is not the same as group health coverage; rates and coverages may be different. For more information, read your insurance booklet or
Summary Plan Description, or contact the employer/plan administrator.
RETIREE COVERAGE AND COBRA: If you are covered by a retiree plan offered by the employer/plan administrator and you lose that retiree
coverage due to a COBRA qualifying event, your coverage may be extended under COBRA. Contact the employer/plan administrator for further
information.
PLAN INFORMATION: For detailed plan information, please refer to your insurance booklet. Your “insurance booklet” may be referred to as a
Summary Plan Description (SPD), benefits booklet or Certificate of Coverage which may be available by contacting the employer/plan administrator
listed above. The information contained in the insurance booklet may not be altered by any statements made by representatives of the employer/plan
administrator. Some states also have health insurance continuation rules. Please check your insurance booklet for further information regarding
specific state continuation laws that may apply to you.
WHY SHOULD I ELECT COBRA?: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) created creditable coverage, which
includes COBRA. Creditable coverage may impact a preexisting condition exclusion period on another health plan. Under HIPAA, employers and
carriers are required to count creditable coverage towards a preexisting condition exclusion period, thus reducing the time a preexisting condition is
not covered, as long as you do not exceed 63 days without creditable coverage. By electing COBRA, you may reduce the possibility of a gap in
coverage and the preexisting condition exclusion period under another plan. If you fail to timely elect and pay for COBRA, you may experience a
gap in your insurance coverage and may not be able to use your previous health insurance as a credit towards a preexisting condition limitation or
exclusion.
Date:
August 12, 2017
From:
LAZ Parking
15 Lewis Street
Hartford, CT 06103
To:
Lisa Gregorio
Hunting Rd.
Needham, MA 02494
COBRA CONTINUATION COVERAGE ELECTION FORM
If the address above is incorrect, please make the appropriate change. If you are making an address change, also please notify your former employer
and carriers of this change.
COBRA Coverages and Premiums
Event
Loss of
Must
Date
Coverage
Elect By
Plan Coverage
Option
Event
Anthem
MEDICAL
Family
Guardian
DENTAL
Family
End of Employment
8/20/2012
9/1/2012
End of Employment
8/20/2012
9/1/2012
Coverage
Expires
Premium
Day Due
11/1/2012
3/1/2013
$400.89
1st
11/1/2012
3/1/2013
$27.21
1st
LIST PERSON(S) ELECTING COBRA:
All qualified beneficiaries have independent election rights.
First Name
Last Name
SS#
Coverage Desired
Birth Date
______________________
______________________________
______________________
______________________ ___/___/___
______________________
______________________________
______________________
______________________ ___/___/___
______________________
______________________________
______________________
______________________ ___/___/___
______________________
______________________________
______________________
______________________ ___/___/___
I/We understand that my/our COBRA coverage may be retroactively terminated if I /we misrepresent any facts on this election form or any other
insurance document. I/we hereby apply for COBRA coverage for myself and/or the individuals listed on this form. I/we understand that all
retroactive premiums are due within 45 days of the date I/we elect and that I/we elect and that premium payments may be made in monthly
installments. I/we understand that the employer/plan administrator is not required to provide billing statements.
_____________________________________________________
Signature (Please copy this form for your records.)
Return the completed form and payment to:
_________________
Date
_____________________
Daytime Phone Number
Wentworth, DeAngelis & Kaufman
ATTN: Tammy Davis
74 Batterson Park Rd
Farmington, CT 06032
CARRIER NOTE: This form is an individual written request for you to provide the same coverage to qualified beneficiaries that you provide to
active employees (TAMRA 1988).
Connecticut Continuation Coverage Notice SUPPLEMENT
For use by group health insurers and group policyholders for qualified beneficiaries enrolled in
Continuation Coverage on May 5, 2010 or
who experience a qualifying event on May 5, 2010 or later
Date of Notice:
August 12, 2017
Dear:
Lisa Gregorio
(Name of Qualified Beneficiary(ies)
This notice contains important information about your right to continue your group health
insurance coverage for up to 30 months with
LAZ Parking (the Plan).
(Name of Group Health Plan)
THIS SUPPLEMENT IS BEING DISTRIBUTED TO YOU
TO CONFIRM YOUR PLAN’S COMPLIANCE WITH
CONNECTICUT PUBLIC ACT 10-13
Please read the information contained in this notice carefully
Connecticut Public Act 10-13 extended the maximum continuation period for certain qualifying
events from 18 months to 30 months. This change applies to individuals who are currently on
state or federal COBRA continuation through coverage under a Connecticut group health
insurance policy as well as to individuals covered under a Connecticut group health insurance
policy who experience a qualifying event on May 5, 2010 or later.
You are receiving this notice because either: (1) you are currently on continuation coverage as
of May 5, 2010 (effective date of new law and your 18 month continuation period did not expire
prior to May 5, 2010), or (2) you have experienced a qualifying event on May 5, 2010 or later. If
your loss of health coverage was due to a lay-off, termination of employment (except for gross
misconduct), leave of absence or reduction in hours, you are eligible for extended continuation
coverage up to 30 months, from the beginning date of your continuation coverage, provided you
meet the other applicable provisions, including paying premiums on a timely basis.
If you have any questions, please contact your COBRA administrator.