election notice form for Connecticut mini-COBRA - ConnectiCare

5In considering whether to elect continuation coverage, you should take into account that a failure to continueyour group health coverage will affect your future rights under state and federal law. First, you can lose theright to avoid having preexisting condition exclusions applied to you by other group health plans if you have a150-day gap in health coverage, and election of continuation coverage may help prevent such a gap. Second,you will lose the guaranteed right to purchase individual health coverage that does not impose a preexistingcondition exclusion if you do not elect continuation coverage for the maximum time available to you. Finally,you should take into account that you have special enrollment rights under federal law. You have the right torequest special enrollment in another group health plan for which you are otherwise eligible (such as a plansponsored by your spouse’s employer) within 30 days after your group health coverage ends because of thequalifying event listed above. You will also have the same special enrollment right at the end of continuationcoverage if you get continuation coverage for the maximum time available to you.How much does continuation coverage cost?Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. Theamount a qualified beneficiary may be required to pay may not exceed 102 percent (or, in the case of anextension of continuation coverage due to a disability, 150 percent) of the cost to the group health plan(including both employer and employee contributions) for coverage of a similarly situated plan participant orbeneficiary who is not receiving continuation coverage. The required payment for each continuation coverageperiod for each option is described in this notice.The American Recovery and Reinvestment Act of 2009 (ARRA) reduces the continuation coverage premium insome cases. The premium reduction is available to certain individuals who experience a qualifying event that isan involuntary termination of employment during the period beginning with September 1, 2008 and ending withDecember 31, 2009. If you qualify for the premium reduction, you need only pay 35 percent of the continuationcoverage premium otherwise due to the issuer. This premium reduction is available for up to nine months. Ifyour continuation coverage lasts for more than nine months, you will have to pay the full amount to continueyour continuation coverage. See the attached “Summary of the Continuation Coverage Premium ReductionProvisions under ARRA” for more details, restrictions, and obligations as well as the form necessary toestablish eligibility.The Trade Act of 2002 created a tax credit for certain individuals who become eligible for trade adjustmentassistance and for certain retired employees who are receiving pension payments from the Pension BenefitGuaranty Corporation (PBGC). Under the tax provisions, eligible individuals can either take a tax credit or getadvance 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 ofcontinuation coverage for PBGC recipients (covered employees who have a nonforfeitable right to a benefit anyportion of which is to be paid by the PBGC) and TAA-eligible individuals. Contact your former employer ifyou think you might be eligible for the TAA program.If you have questions about these provisions, you may call the Health Coverage Tax Credit Customer ContactCenter toll-free at 1-866-628-4282. TTD/TTY callers may call toll-free at 1-866-626-4282. More informationabout the Trade Act is also available at www.doleta.gov/tradeact.

6When and how must payment for continuation coverage be made?Please ask your former employer to complete the information on this page.First payment for continuation coverageIf you elect continuation coverage, you do not have to send any payment with the Election Form. However, youmust make your first payment for continuation coverage not later than 45 days after the date of your election.(This is the date the Election Notice is post-marked, if mailed.) If you do not make your first payment forcontinuation coverage in full not later than 45 days after the date of your election, you will lose all continuationcoverage rights under the Plan. You are responsible for making sure that the amount of your first payment iscorrect. You may contact your former employer or ConnectiCare to confirm the correct amount of your firstpayment or to discuss payment issues related to the ARRA premium reduction.Monthly payments for continuation coverageAfter you make your first payment for continuation coverage, you will be required to make monthly payments.The amount due for each month for each qualified beneficiary is shown in this notice (Section 1B). Under thePlan, each of these monthly payments for continuation coverage is due on the first day of the month. If youmake a monthly payment on or before the first day of the month to which it applies, your coverage under thePlan will continue for that month without any break.Grace periods for monthly paymentsAlthough monthly payments are due on the dates shown above, you will be given a grace period of 30 daysafter the first day of the month to make each monthly payment. Your continuation coverage will be provided foreach month as long as payment for that month is made before the end of the grace period for that payment.However, if you pay a monthly payment later than the first day of the month to which it applies, but before theend of the grace period for the month, your coverage under the Plan may be suspended as of the first day of themonth and then retroactively reinstated (going back to the first day of the month) when the monthly payment isreceived. This means that any claim you submit for benefits while your coverage is suspended may be deniedand may have to be resubmitted once your coverage is reinstated.If you fail to make a monthly payment before the end of the grace period for that month, you will lose all rightsto continuation coverage under the Plan.Your first payment and all monthly periodic payments for continuation coverage should be sent to your formeremployer at:___________________________________________________________________________________________________________________________________________________________________________________________________________________________Your former employer will complete Section 1B. If you have questions or want to confirm the correct amountof your first payment, you can contact ConnectiCare’s billing Department at 1-800-333-1733.

7For more informationThis notice does not fully describe continuation coverage or other rights with respect to your coverage. Moreinformation about continuation coverage or other rights under the Plan is available in your group healthinsurance certificate or from your former employer.If you have any questions concerning the information in this notice or your rights to coverage you shouldcontact your former employer. Please ask your former employer to put their contact information here:Continuation Coverage Administrator: _______________________________________________________Address: _______________________________________________________________________________Telephone Number: ______________________________________________________________________For more information about your rights under state law, contact the Connecticut Insurance Department,Division of Consumer Affairs at 1-800-203-3447.Keep Your Plan Informed of Address ChangesIn order to protect your and your family’s rights, you should keep your former employer and ConnectiCareinformed 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 your former employer and ConnectiCare.

8Section 1B – Bring to former employer who will be able to fill in the rate and coverage termapplicable to youIf elected, continuation coverage will begin on ____________________ and can last until ______________.You may elect any of the following options for medical coverage under Connecticut Continuation coverage: Medical - $ __________ per monthOption AIf you qualify as an “Assistance Eligible Individual”the rate is $ ______________ per month for up to9 months.Rate quoted is for: Employee$_____________ full premium (A) Employee + Spouse$(-)___________ employer contribution (if any) (B) Employee + 1$(=)___________ subsidy eligible premium (C) Employee + Child(ren) $(-) ___________subsidy premium (65% of C) Family $(=)___________ your monthly premium (35%)---------------------------------------------------------------------------------------------------------------------------------------Section 1CYou do not have to send any payment with the Election Form. Important additional information about paymentfor continuation coverage is included in the pages following the Election Form.If you have any questions about this notice or your rights to continuation coverage, you should contact yourformer employer. Please ask your former employer to put their contact information here:Name of Continuation Coverage Administrator: (former employer) ___________________________________Address; __________________________________________________________________________________Telephone #: _______________________________________________________________________________

9Section 2A – If you do not have continuation coverage now, use this form to enrollContinuation Coverage Election FormInstructions: To elect continuation coverage, complete this Election Form and give it to your formeremployer. You have 60 days after the date of this notice to decide whether you want to electcontinuation coverage. Please ask your former employer to put their contact information here:Send completed Election Form to: (former employer) _________________________________________Address:________________________________________________________________________________________________This Election Form must be completed and returned to your former employer no later than 6/17/09. Ifmailed, it must be post-marked no later than 6/17/09 (60 days from the date of Election Notice.)If you do not submit a completed Election Form by the due date shown above, you will lose your rightto elect continuation coverage. If you reject continuation coverage before the due date, you may changeyour mind as long as you furnish a completed Election Form before the due date. However, if youchange your mind after first rejecting continuation coverage, your continuation coverage will begin onthe date you furnish the completed Election Form.I (We) elect continuation coverage in the _____________________________ (the Plan) as indicatedbelow:former employer’s group medical planName(First and Last Name)Relationshipto EmployeeSocial SecurityNumberDate ofBirthElectingMedicalYes NoYes NoYes NoYes No_____________________________________Signature______________________________________Print Name__________________________________________________________________________________________________________________Print Address (home mailing address)_____________________________Date_____________________________Relationship to individual(s) listed above______________________________Telephone number

10Section 3A – Request for treatment as an assistance eligible individualTo apply for ARRA Premium Reduction, complete this form and return it to your former employer along with yourElection Form, (Section 2A if applicable.)You may also send this form in separately. If you choose to do so, send the completed “Request for Treatmentas an Assistance Eligible Individual” to: your former employer. Please ask your former employer to put theircontact information below.You may also want to read the important information about your rights included in the “Summary of theContinuation Coverage Premium Reduction Provisions Under ARRA.”Employer Name:_________________________________________________PERSONAL INFORMATIONName and mailing address of employee (list any dependents on the back ofthis form)Employer Mailing Address________________________________________________________________________________________________________Telephone numberE-mail address (optional)To qualify, you must be able to check ‘Yes’ for all statements.1. The loss of employment was involuntary. Yes No2. The loss of employment occurred at some point on or after September 1, 2008 and on or before December 31, 2009. Yes No3. I elected (or am electing) continuation coverage. Yes No4. I am NOT eligible for other group health plan coverage (or I was not eligible for other group health plan coverage Yes Noduring 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 Yes Nopremium).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 haveprovided on this form are true and correct.Signature__________________________________________________ Date _________________________________________Type or print name__________________________________________ Relationship to employee _________________________Section 3B – Covered dependentsDEPENDENT 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) continuation coverage. Yes No2. I am NOT eligible for other group health plan coverage. Yes No3. I am NOT eligible for Medicare. Yes NoI make an election to exercise my right to the ARRA Premium Reduction. To the best of my knowledge and belief all of the answers Ihave provided on this form are true and correct.Signature __________________________________________________ Date ______________________________________Type or print name__________________________________________ Relationship to employee _________________________

11Name Date of Birth Relationship to Employee SSN (or other identifier)b. _________________________________________________________________________1. I elected (or am electing) continuation coverage. Yes No2. I am NOT eligible for other group health plan coverage. Yes No3. I am NOT eligible for Medicare. Yes NoI make an election to exercise my right to the ARRA Premium Reduction. To the best of my knowledge and belief all of the answers Ihave 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) continuation coverage. Yes No2. I am NOT eligible for other group health plan coverage. Yes No3. I am NOT eligible for Medicare. Yes NoI make an election to exercise my right to the ARRA Premium Reduction. To the best of my knowledge and belief all of the answers Ihave provided on this form are true and correct.Signature __________________________________________________ Date ______________________________________Type or print name __________________________________________ Relationship to employee _________________________(If you need space to list additional dependents please make a copy of this page and submit with this form.)---------------------------------------------------------------------------------------------------------------------------------------Section 3CFORMER EMPLOYER MUST COMPLETEThis 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. If this application is approved, send the original ofthis form to ConnectiCare, Attn: enrollment, at 175 Scott Swamp Road, Farmington, CT 06032REASON FOR DENIAL OF TREATMENT AS AN ASSISTANCE ELIGIBLE INDIVIDUAL1. 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 here)5. Employer is contributing $ _____________ to coverageThe employer has 19 or fewer employees and is subject to the state continuation laws (“mini”-COBRA) rather than federal COBRA law.Signature of person at employer responsible for continuation coverage administration for the Planx ______________________________________________________________ Date _________________________________________Type or print name ______________________________________________________________________________________________Telephone number _______________________________________________E-mail address _________________________________

13Participant NotificationThis form is designed for ConnectiCare to distribute to qualified beneficiaries who are paying reduced premiumspursuant to ARRA so they can notify ConnectiCare if they become eligible for other group health plan coverage orMedicare.Use this form to notify ConnectiCare that you are eligible for other group health plan coverageor Medicare.ConnectiCare175 Scott Swamp Road, Farmington, CT 06032Attn: EnrollmentPERSONAL INFORMATIONName and mailing addressTelephone numberE-mail address (optional)PREMIUM REDUCTION INELIGIBILITY INFORMATION – Check oneI 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______________________ IMPORTANTIf you fail to notify ConnectiCare of becoming eligible for other group health plan coverage or Medicare ANDcontinue to pay reduced continuation coverage premiums you could be subject to a fine of 110% of the amount ofthe 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 theirnames here:____________________________________________________________________________________________________________________________________________________________________