CALIFORNIA - Pacificare Health Systems

PART A
106
This coverage is subject to the following conditions:
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Member Eligibility
The former employee worked for the employer for
the prior five (5) years and was 60 years of age or
older on the date his or her employment ended
and;
The former employee was eligible for and elected
COBRA for himself or herself and his or her
dependent Spouse or;
A former Spouse (i.e., a divorced or widowed
Spouse as described above) is also eligible for
continuation of group coverage after they have
used all of their available COBRA benefit coverage.
The former Spouse must elect such coverage by
notifying PacifiCare in writing within 30 calendar
days prior to the date that the initial COBRA
benefits are scheduled to end. A former Spouse
or surviving Spouse may continue Continuation
COBRA for up to five (5) continuous years
upon the coverage prior to the effective date of
cancellation. If you are terminated for failing to
make timely Premium, you are not eligible for the
PacifiCare Individual Conversion Plan described
in the section titled, “Extending Your Coverage:
Converting to an Individual Conversion Plan.”
If elected, this coverage will begin after your 36th
month of COBRA coverage and will be administered
under the same terms and conditions as if
COBRA had remained in force. If you are already
a California Continuation COBRA participant or
will become eligible as of December 1, 2004, your
extended coverage will remain in place until you
are automatically terminated per the below section,
“Termination of Continuation Coverage After COBRA
for Certain Employees and their Spouses as Described
in the Above Paragraph.” As your former employer’s
premium is not adjusted for the age of the specific
employee or Eligible Dependent, premiums for this
coverage will be 213 percent of the current applicable
group rate. Your premium may be increased or your
benefit package decrease each time the Employer’s
Group’s benefit package renews or changes. Payment is
due at the time the Employer Group’s payment is due.
For California Continuation Coverage, PacifiCare will
bill you directly once we have received your election
form. You are responsible for paying the Health Plan
Premium directly to PacifiCare on a month basis, and
it must be delivered by first-class mail or other reliable
means.
The first month’s California Continuation COBRA
Health Plan Premium payment is due within 45
days of the date that you submit the election form
to PacifiCare. This payment must be sufficient to
pay all premiums due from the first month after the
qualifying event through the current month. Failure
to submit the correct premium amount will disqualify
you from receiving California Continuation coverage.
Please note, you will not be enrolled in California
Continuation COBRA until PacifiCare receives both
your election form and your first premium payment.
Thereafter, California Continuation Coverage
premiums are due on the first day of the coverage
month (i.e., January 1st for January coverage). If you
fail to pay your premium when the premium payment
is due, PacifiCare will send you a 15-day cancellation
notice reminding you that your premium is overdue.
If premium is received within 15 days of PacifiCare’s
cancellation notification you will experience no break
in coverage and no changes in benefits. However if
you do not pay your premium, enrollment will be
cancelled effective 15 days after PacifiCare mailed
the cancellation notice. A termination notice will be
sent to you at this time, and any premium payments
received after the 15-day notice period has expired for
coverage after the effective date of cancellation will be
refunded to you within 20 business days. However, you
remain financially responsible for unpaid premium for
coverage prior to the effective date of cancellation. If
you are terminated for failing to make timely premium,
you are not eligible for the PacifiCare Individual
Conversion Plan described in the section titled,
“Extending Your Coverage: Converting to an Individual
Conversion Plan.”
Termination of Continuation Coverage After
COBRA for Certain Employees and Their
Spouses as Described in the Above Paragraph
This coverage will end automatically on the earlier of:
1. The date the former employee, Spouse or former
Spouse reaches 65;
2. The date in which the Group Agreement contract
is terminated by either your former Employer
Group or PacifiCare or the date your former
employer ceases to provide coverage for any
active employees through PacifiCare;
3. The date the former employee, Spouse or former
Spouse is covered by another Health Plan;