CALIFORNIA - Pacificare Health Systems

PART B
188
Section 8 – Disenrollment From the Secure
Horizons Group Retiree Medicare Advantage Plan
Center within sixty (60) days of the event or
eligibility to elect continuation coverage will
be lost.
Continuation – Once aware of a Qualifying
Event, the Employer will give a written
election notice of the right to continue
the coverage to you (or to the Qualified
Beneficiary in the event of your death). Such
notice will state the amount of the Premium
required for the continued coverage. If a
person wants to continue the coverage, the
Election Notice must be completed and
returned to the address below, along with the
first month’s Premium within sixty (60) days
of the later of:
1. the date of the Qualifying Event; or
2. the date the Qualified Beneficiary received
notice informing the person of the right to
continue.
PacifiCare of California
701 Katella Avenue
Cypress, CA 90630-5028
Benefits of the continuation plan are identical
to this group medical plan and cost is
explained below under “Cost of Continuation
Coverage.”
The continued coverage period runs
concurrently with any other University
continuation provision (e.g., during leave
without pay) except continuation under
the Family and Medical Leave Act (FMLA).
Coverage will be continued from the date
it would have ended until the first of these
events occurs:
1. With respect to yourself and any Qualified
Beneficiaries, the day 18 months from the
earlier of the date:
a. your employment ends for a reason
other than gross misconduct, or
b. your work hours are reduced. But,
coverage may continue for all Qualified
Beneficiaries for up to 11 additional
months while the Qualified Beneficiary
is determined to be disabled under
Title II or XVI of the United States
Social Security Act if:
i. the disability was determined to
exist at the time, or during the first
sixty (60) days, of the 18 months
of COBRA coverage, and
ii. the person gives PacifiCare written
notice of the disability within sixty
(60) days after the determination
of disability is made and within 18
months after the date employment
ended or work hours were
reduced.
PacifiCare must be notified if there is a final
determination under the United States Social
Security Act that the person is no longer
disabled. The notice must be provided within
thirty (30) days after the final determination.
The coverage will end on the first of the
month that starts more than thirty (30) days
after the determination.
1. With respect to your Qualified
Beneficiaries (other than yourself), the day
36 months from the earliest of the date:
a. of your death; or
b. of your entitlement to Medicare
benefits; or
c. of your divorce, annulment or legal
separation from your spouse; or
d. your Dependent child ceases to be an
eligible Dependent under the rules of
the plan.
The 36 months will be counted from the date
of the earliest Qualifying Event.
With respect to any Qualified Beneficiary:
1. If the person fails to make any Premium
payment required for the continued
coverage, the end of the period for
which the person has made the required
payments.
2. The day the person becomes covered
(after the day the person made the
election for continuation of coverage)
under any other group Health Plan, on
an insured or uninsured basis. This item