COBRA SBCCOE Benefit Plan Continuation of Medical/Dental Election Form

COBRA SBCCOE Benefit Plan Continuation of Medical/Dental/Vision/FSA Election Form

Agency/College Name Date Form Provided To Employee______COBRA Qualifying Date, (your coverage will end on this date if you do not elect COBRA) The State Board for Community Colleges & Occupational Education (SBBCOE) Benefit Plan provides that employees and their qualified dependents whose medical/dental/vision coverage would otherwise terminate due to events called “qualified events” may elect to continue coverage for themselves and/or their qualified dependents currently covered. If you do not submit a completed Election Form by the due date shown on the bottom of this form, you will lose your right to elect COBRA continuation coverage. If you reject COBRA continuation coverage before the due date, you may change your mind as long as you furnish a completed Election Form before the due date. Read the important information about your rights included on the back of this form. FOR HUMAN RESOURCES OFFICE ONLY Current Medical Plan and Option Monthly COBRA Premium

Current Dental Plan and Option Monthly COBRA Premium

Current Vision Plan Monthly COBRA Premium

Health Flex Spending Account (FSA) Monthly COBRA Premium Check the qualifying event/months of eligible coverage that applies:  Voluntary Termination of employment/retirement / 18  Death of an employee / 36 mos mos  Involuntary Termination of employment / 18 mos  Divorce, legal separation or termination of domestic partnership / 36 mos  Reduction of work hours / 18 mos  Entitlement to Medicare for covered employee / up to 36 mos depending on date employee qualified for Medicare  Disability retirement/termination / 29 mos w/Proof of  Child losing eligibility / 36 mos Disability TO ELECT COBRA CONTINUATION COVERAGE COMPLETE THE FOLLOWING – Contact 24Hour Flex-COBRA if your address changes while covered

Last Name First Name Primary Phone

Mailing Address  I wish to continue COBRA Coverage (complete  I decline/waive my COBRA coverage (skip to signature section of form) remainder of form) PARTICIPANTS TO BE COVERED UNDER COBRA – Attach separate page to include additional dependents if necessary To be eligible for COBRA, the individual(s) must have been enrolled under the employee’s coverage prior to the qualifying date. List all persons (including yourself) and indicate the type of coverage you are selecting to continue under COBRA. Select Yes or No under Medicare Eligible/Enrolled. If you or any dependents are eligible for other medical/dental benefits, complete the section below.* If elected, coverage will begin on ______and can last until ______unless coverage is terminated as described on the back of this form. Continu Continu e e M D Medicar e Continu Continu e e d e e FSA Name: Last, First, MI (Attach additional Social Security Sex Birth n Eligible/ i Vision Plan sheet if needed) Number M/F Date t Enrolled c a a l l Ye Ye Ye Ye Ye No No No No No s s s s s Employee Spouse/DP  Current or  Former Child

Child *OTHER MEDICAL/DENTAL COVERAGE INFORMATION – Complete if you or any of your covered dependents are eligible for other medical/dental coverage Policyholder Name: Policy Number : Other Carrier Name and Address: Organization through which coverage is offered and address: COBRA ELECTION SIGNATURE (Must be signed and dated) I have read this form and the notice of my election rights. I understand my rights to elect continuation coverage and would like to take the action indicated above. I understand that if I elect continuation coverage, my continuation coverage will terminate under several circumstances according to COBRA regulations, including: non-payment of premium, the date I or a continued dependent become covered under another Group Health Plan or become entitled to Medicare after the COBRA election, or on the date which this Group Plan ends. I also understand that if I was determined to be disabled by the Social Security Administration within 60 days of my Qualifying Event, I may be eligible for extended continuation coverage and that any break in continued coverage of more than 63 days may cause loss of coverage portability. Employee * Dependent Signature * Spouse/DP Signature Date:  Current or  Former Date: Date:

* If applying for or declining coverage on his/her own This Election Form must be completed and returned (post-marked, faxed or emailed) no later than to: WHITE copy: 24Hour Flex-COBRA, 7100 E Belleview Ave, Suite 300, Greenwood Village, CO 80111 or Fax: 1-877-454-3044 or [email protected] PINK copy: Human Resources file copy. YELLOW copy: Retain for your records. Revised (6/13) COBRA SBCCOE Benefit Plan Continuation of Medical/Dental/Vision Election Notice This notice contains important information about your right to continue your health care coverage in the SBCCOE Benefit Plan (the Plan), as well as other health coverage alternatives that may be available to you through the Health Insurance Marketplace. Please read the information contained in this notice and form very carefully. You have 60 days from the date of this notice to decide whether you want to elect COBRA continuation coverage under the Plan. There may be other coverage options for you and your family. When key parts of the health care law take effect, you will be able to buy coverage through the Health Insurance Marketplace. In the Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums right away, and you can see what your premium, deductibles, and out-of- pocket costs will be before you make a decision to enroll. Being eligible for COBRA does not limit your eligibility for coverage for a tax credit through the Marketplace. Additionally, you may qualify for a special enrollment opportunity for another group health plan for which you are eligible (such as a spouse’s plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days of your COBRA qualifying date. 1. Coverage: The front of this form shows the length of coverage depending on the qualifying event. 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 open enrollment and special enrollment rights. You must request any change to status (such as newborn, adoption, etc.) within thirty-one (31) days of the event. 2. Extension of Length of Coverage: If you elect continuation coverage, an extension of the maximum period of coverage may be available if a qualified beneficiary is disabled or a second qualifying event occurs. You must notify 24Hour Flex-COBRA of a disability or a second qualifying event in order to extend the period of continuation coverage. . Disability: An 11-month extension may be available if the Social Security Administration (SSA) determines any of the qualified beneficiaries to be disabled. The disability has to have started at some time before the 60th day of COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. Each qualified beneficiary who has elected continuation coverage will be entitled to the 11-month disability extension if one of them qualifies. If SSA determines the qualified beneficiary to no longer be disabled, you must notify 24Hour Flex-COBRA of that fact within 30 days after the SSA’s determination. . Second Qualifying Event: An 18-month extension of coverage will be available to spouses and dependent children who elect continuation coverage if a second qualifying event occurs during the first 18 months of continuation coverage. The maximum amount of continuation coverage available when a second qualifying event occurs is 36 months. Such second qualifying events may include the death of a covered employee, divorce or separation from the covered employee, the covered employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both), or a dependent child’s ceasing to be eligible for coverage as a dependent under the Plan. These events can be a second qualifying event only if they would have caused the qualified beneficiary to lose coverage under the Plan if the first qualifying event had not occurred. can extend an original 18 month COBRA coverage period to 36 months. Under the rules, if the initial qualifying event (termination of employment or reduction of hours) occurs after Medicare entitlement, then the maximum COBRA coverage period for the covered spouse and dependents ends 36 months from date of Medicare entitlement or 18 months from the termination of employment or reduction of hours, whichever is later. . You must notify the Plan within 60 days after a second qualifying event occurs if you want to extend your continuation coverage. 3. How to elect coverage: To elect continuation coverage, you must complete and submit this Election Form to the directions. Each qualified beneficiary has a separate right to elect continuation coverage. For example, the employee’s spouse may elect continuation coverage even if the employee does not. Continuation coverage may be elected for only one, several, or for all dependent children who are qualified beneficiaries. A parent may elect to continue coverage on behalf of any dependent children. The employee or the employee's spouse can elect continuation coverage on behalf of all of the qualified beneficiaries. 4. Payment of Premiums . First Payment: You do not have to send any payment with the Election Form, however you must make your first payment for continuation coverage not later than 45 days after the date of your election (the date the Election Notice is post-marked.) Your coverage will not reinstate until 24Hour Flex-COBRA receives payment. You are responsible for making sure that the amount of your first payment is correct. You may contact 24Hour Flex-COBRA to confirm the correct amount of your first payment. . Periodic payments: After enrolling, you will receive a coupon book from 24Hour Flex-COBRA, however a coupon is not required to make a payment.. Each periodic payment is due by the date shown on the coupon. You can also contact 24Hour Flex-COBRA to establish online access for payments. If you make a periodic payment on or before the first day of the coverage period to which it applies, your coverage under the Plan will continue for that coverage period without any break. . Grace Periods: Although periodic payments are due on the dates shown on your coupons, you will be given a grace period of 30 days after the first day of the coverage period. Your continuation coverage will be provided for each coverage period as long as payment for that coverage period is made before the end of the grace period for that payment. 5. Termination of Coverage: coverage will be terminated before the end of the maximum period if: . Any required premium is not paid in full on time. You will be responsible for the full cost of health services incurred during any coverage period for which you did not submit payment. . A qualified beneficiary becomes covered, after electing continuation coverage, under another group health plan that does not impose any pre-existing condition exclusion for a pre-existing condition of the qualified beneficiary (note: there are limitation on plans’ imposing a pre-existing condition exclusion and such exclusions will become prohibited beginning in 2014 under the Affordable Care Act), . A qualified beneficiary becomes entitled to Medicare benefits (under Part A, Part B, or both) after electing continuation coverage, . Any reason the Plan would terminate coverage for a participant or beneficiary not receiving continuation coverage (such as fraud), or . The employer ceases to provide any group health plan for its employees. This notice does not fully describe continuation coverage or other rights under the Plan. For Summary Plan Descriptions, additional information or any questions, or IF YOUR ADDRESS CHANGES, contact 24Hour Flex-COBRA at 303-369- 7886 or 800-651-4855. For more information about your rights under COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, visit the US Department of Labor’s Employee Benefits Security Administration (EBSA) website at www.dol.gov/ebsa or call 1-866-444-3272. For more information about health insurance option available through the Health Insurance Marketplace, visit www.healthcare.gov. Revised (6/13)