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IBEW Local 11-LA NECA Active Health Plan
Summary Plan Description (SPD)

COBRA

Introduction

The Consolidated Omnibus Budget Reconciliation Act of 1985, as amended ("COBRA), requires that this plan offer you and your eligible dependents the opportunity for a temporary extension of health care coverage at group rates in certain instances when coverage under the plan would otherwise end (called "qualifying event").  Continued coverage under COBRA applies to the health care benefits described in this booklet.

The benefits under COBRA are the same as those covering people who are not on continuation coverage.  You should also keep in mind that each individual entitled to coverage as the result of a qualifying event has a right to make his or her own election of coverage.  For example, your spouse or other covered dependent may elect COBRA coverage even if you do not.

IMPORTANT, the continuation of health care coverage as explained below requires that you must make a payment each month to the Administrative Office within the time periods explained below.  Don’t forget that the Administrative Office does not send bills for COBRA coverage and that it is your responsibility to make COBRA payments on time.  If you don’t make your payment on time, your coverage will end.

Under the law, you have sixty (60) days from the date you lose coverage because of certain events to inform the Administrative Office that you want COBRA continuation coverage.  Also, please note that you have sixty days after you receive the COBRA election notice from the Administrative Office to notify the Administrative Office that you are electing COBRA continuation coverage. You must make your first payment to the Trust Fund for COBRA continuation coverage within forty-five (45) days after you first elect COBRA coverage.

When you make your first COBRA payment, you must pay for all months, which are due. Payment for subsequent months are due on the first of each month, and your COBRA coverage will terminate for non-payment if payment is not received in the Administrative Office within 30 days.  For example, a payment for the coverage month of January is due January 1st, and if payment is not received in the Administrative Office by January 30th, your COBRA continuation coverage will end. Thus, there is no coverage for January.

You, your spouse, and children should read this section carefully. The following information explains both your rights and your obligations under the continuation coverage provision of the COBRA law. If you have any questions, contact the Trust Fund Administrative Office. The phone number and address are printed under the "Summary Plan Description General Information" in the front of this booklet.

Frequently Asked Questions and Answers

The following questions and answers should help you understand your COBRA rights.

Q. Provide a common example of a situation, which might occur, causing me to lose my eligibility for benefits under the Trust.
A. Your eligibility terminates because you are no longer working the required hours to maintain eligibility under the Plan. This event would qualify you to continue coverage under COBRA by making a self-payment.

Q. How long are my COBRA benefits available?
A. A qualified participant is entitled to 18 months of continued coverage if the qualifying event is termination of employment or a reduction of employment hours. This may be extended 11 months if you are considered disabled under the Social Security Act. Any other qualifying event increases the available coverage term for qualified beneficiaries to 36 months (maximum). Refer to the "Qualifying Events" section below.

Q. I am an employee and make COBRA payments. Are my dependents covered for Plan benefits?
A. Yes, provided they are eligible dependents, as defined by the Plan. Refer to section; "Eligibility and General Plan Provisions" subtitle "Eligible Dependents" for a complete description of eligible dependents. Also, children born or adopted during the period of continuation coverage are considered dependents, the same as those of active eligible employees. (However, this applies only if the covered employee elects COBRA coverage during the election period and enrolls the new child upon birth or adoption.)

Q. If I continue coverage under COBRA, can I change my choice of medical Plans?
A. Yes, you can change your choice of medical Plans (from among the plans being offered) during the annual open enrollment period. Refer to section, "Rolling Twelve-Month Open Enrollment Procedures" for details on the open enrollment.

Q. What if I shift from active coverage to retiree coverage?
A. A shift from active to retiree coverage is an open enrollment right, and you have the same rights that an active employee receiving coverage through employment is entitled to.  On this basis, COBRA serves as a bridge to retiree coverage.

Q. How is the COBRA self-payment calculated?
A. Under the COBRA law, the Trustees are permitted to base the self-payment on a formula, which is the Plan cost plus 2% for administration. For example, if you are covered under either Kaiser or PacifiCare, your monthly COBRA payment for continuation coverage is based on the applicable HMO premium cost, and prescription drug cost, plus 2% for administration.  Note, for a disabled qualified participant, the premium for months 19 through 29 may be no more than 150% of the applicable non-COBRA premium.

Q. How often do I make a COBRA self-payment?
A. Payments must be paid monthly.

Q. What is "basic" coverage?
A. Basic coverage includes medical (either Kaiser, PacifiCare or Self-Funded Indemnity Plan). These medical plans include the prescription drug plan benefits as described in this SPD.

This section added by: Amendment 15b.   View Previous Language

Q. Have the Trustees adopted any temporary pilot program for subsidized COBRA coverage?
A. Yes. For certain participants and beneficiaries the self-payment is $50.00 per month for the first three consecutive months of continuation of "Basic Coverage" of hospital/medical and prescription drug benefits. Benefits for dental and vision can be added for an additional cost. Thereafter, on the fourth month of continuation coverage, the self-payment will increase to the full amount allowed under COBRA. Life Insurance benefits are not continued by COBRA.

Q. Who is eligible for this special subsidized rate?
A. Participants receiving a pension from the Southern California IBEW-NECA Pension Plan and their dependents are not eligible. Participants who are "working members" designated as such under a collective bargaining agreement and their dependents are not eligible. Spouses losing coverage due to divorce are not eligible. Children losing coverage due to attainment of an age beyond a maximum age permitted for dependent coverage under this Plan are not eligible.

This section added by: Amendment 26.
Participants who are employed by an employer who are permitted to receive increased wages in lieu of health coverage are not eligible. Participants who decline to reciprocate contributions to the Southern California IBEW-NECA Health Trust Fund while employed by an employer that contributes to a health plan or fund that is signatory to the International Reciprocal Agreement are not eligible.
All participants (employees) who are not working members are eligible. The spouse of such a participant losing coverage due to the participant's death is eligible. The children of such a participant losing coverage due to death or divorce are eligible. It is important to remember that while participants, spouses and children have separate and distinct COBRA election rights, the election by a participant provides coverage for the participant's eligible dependents and the election by any parent provides coverage for the parent's eligible children.

Q. When will I again be eligible for the COBRA self-payment of $50.00 per month?
A. After you have reestablished your Hours Bank Reserve to a maximum of 600 hours. The Hours Bank Reserve is explained under the section, "Eligibility & General Plan Provisions" subtitle "Continuation of Eligibility – Hours Bank Reserve".

Q. Will the Trustees always offer the COBRA self-payment of $50.00 for the first three months?
A. Not necessarily. The Trust subsidy of COBRA self-payments is not guaranteed, and may be discontinued or reduced at any time with 30 days notice to participants.

At a Glance
Qualifying Events That Entitle You To COBRA

If you Lose Coverage Because of This Reason
(a "qualifying event") 		These People Would Be Eligible For COBRA Coverage Up To
(Measured from the date coverage is lost)
Your employment terminates* You and your covered spouse and children 18 months**
Your working hours are reduced You and your covered spouse and children 18 months**
You die Your covered spouse and children 36 months
You divorce or legally separate Your covered spouse and children 36 months
Your dependent child no longer qualifies as an eligible dependent Your covered children 36 months
You become entitled to Medicare Your covered spouse and children 36 months

*For any reason other than gross misconduct (and including military leave and approved leaves granted according to the Family and Medical Leave Act.)

** Continued coverage for up to 29 months from the date of the initial event may be available to those who, during the first 60 days of continuation coverage, become totally disabled within the meaning of Title II, or Title VXI of the Social Security Act. This additional 11 months is available to employees and enrolled dependent if notice of disability is provided within 60 days after the Social Security determination of disability is issued and before the 18-month continuation period runs out.  The cost of the additional 11 months of coverage will increase to 150% of the full cost of coverage.  Additionally, coverage can be extended for eligible dependents to a maximum of 36 months in the event of death or Medicare entitlement of the employee or divorce or legal separation.

This section modified by: Amendment 16.   View Previous Language

Employees

If you have established eligibility under the Plan, you have the right to choose this continuation coverage if you lose eligibility under this Plan for any reason other than your engaging in Non-Covered Electrical Employment. The date your coverage is lost is the date on which your right to elect COBRA coverage commences. The loss of coverage is treated as the "qualifying event" by the plan. However, an employee will not be eligible for COBRA coverage if the employee's loss of coverage under this Plan is as a result of work in Non-Covered Electrical Employment.

Spouses

If you are the legal spouse of an employee covered for health care benefits under this Plan, you have the right to choose continuation coverage for yourself if you lose health coverage under this Plan for any of the following reasons:

  1. Loss of coverage, including a loss of coverage due to termination of your spouse's employment or reduction in your spouse's hours of employment;
  2. Covered employee's death;
  3. Loss of dependent status under the Plan;
  4. Divorce or legal separation from your spouse;
  5. Your spouse becomes eligible for Medicare; or
  6. Your spouse's employer files for Chapter 11 reorganization.

However, a legal spouse of an employee will not be eligible for COBRA coverage if the employee's loss of coverage under this Plan is a result of the employee's work in Non-Covered Electrical Employment.

Children

If you are a dependent child, as defined under the Section of the Plan entitled "Eligible Dependents", of an employee covered under this Plan, you have the right to choose continuation coverage for yourself if you lose health coverage under this Plan for any of the following reasons:

  1. Loss of coverage by the employee, including loss of coverage due to termination of the employee parent's employment or reduction in the employee's hours of employment;
  2. The divorce or legal separation of the employee parent and his or her legal spouse;
  3. Covered employee parent's death;
  4. The employee parent becomes eligible for Medicare;
  5. The dependent ceases to be a dependent child under the Plan rules, for example, due to a dependent reaching an age which is no longer considered an eligible dependent under the Plan; or
  6. The employee parent's employer files for Chapter 11 reorganization.

In no event will an Eligible Dependent be entitled to continuation coverage if the employee parent's loss of coverage under this Plan is as a result of the employee working in Non-Covered Electrical Employment.

This section added by: Amendment 16.

Domestic Partners

Eligible Domestic Partners as that term is defined under this Plan are not entitled to elect COBRA continuation coverage unless they are enrolled under one of the insured HMO Plans. If an eligible Domestic Partner is enrolled under one of the insured HMO Plans, the Domestic Partner will be entitled to choose continuation coverage under CAL-COBRA for himself or herself upon a loss of coverage under this Plan for a period of up to 36 months for any of the following reasons:

  1. Loss of coverage by the employee, for reasons including a reduction in the number of hours of employment under the Plan; or
  2. The employee's voluntary or involuntary termination of employment with a contributing employer as defined in the "Definitions" section of this booklet;
  3. Death of the covered employee;
  4. The covered employee becomes eligible for Medicare;
  5. The covered employee's employer files for Chapter 11 reorganization.

In no event will a Domestic Partner become eligible for CAL-COBRA continuation coverage if the employee's loss of coverage under this Plan is as a result of his/her working in Non-Covered Electrical Employment.

In no event will termination of a Domestic Partnership constitute a qualifying event entitling the Domestic Partner to CAL-COBRA continuation coverage.

Notification

An employee or a family member has the responsibility to inform the Administrative Office of a divorce, legal separation, or a child losing dependent status under the Plan within 60 days of the qualifying event. A qualifying event means the reason you are losing eligibility under one of the situations described above, such as termination of an employee's employment.  Another example of a qualifying event for a legal spouse would be divorce. For a dependent, he or she may turn age 19 and no longer be an eligible dependent under Plan rules.

When the Administrative Office is notified that one of these events has happened, the Administrative Office will, in turn, notify you that you have the right to choose continuation coverage. This notice will also explain the monthly payment you must pay to continue your health coverage. Under the law, you have at least 60 days from the date you would lose coverage, because of one of the qualifying events described above, to inform the Administrative office that you want continuation coverage.  

Children born or adopted during the period of continuation coverage are considered dependents, the same as those of active eligible employees. Remember, you must enroll your newborn or adopted child. Contact the Administrative Office for the necessary forms to enroll this new dependent.

If you do not choose continuation coverage by making a self-payment, coverage under this Plan will end. You will not be able to elect COBRA Continuation Coverage at a later date.

Benefits & Length of Coverage

If you choose "Basic" continuation coverage, it will be the same hospital/medical/prescription drug coverage, which was previously provided to you under the Plan. A qualified beneficiary is entitled to 18 months of continued coverage if the qualifying event is termination of employment or a reduction of employment hours. This may be extended 11 months, for a total of 29 months within the first sixty (60) days of COBRA coverage an Employee or his dependent(s) are determined to be disabled by the Social Security Administration. To be eligible for the special 11 month extension, the disabled individual must notify the Administrative Office within 60 days following the later of the date on which the individual receives the initial COBRA notice following a qualifying event or the date Social Security determines that the individual is disabled and in all events before the end of the initial 18 month period of COBRA continuation coverage.  Any other qualifying event increases the coverage term for qualified beneficiaries to 36 months (maximum).

If another qualifying event occurs during the 18-month maximum coverage period (29 months in case of a disability extension), the spouse or dependent children may be entitled to an additional 18-month extension for up to 36 months (maximum). In no case may the total amount of continued coverage be more than 36 months.

Cancellation of Your COBRA Coverage

Your COBRA coverage may be terminated prior to the Coverage Period allowed under COBRA for any of the reasons explained below.

  1. Coverage has continued for the maximum 18, 29 or 36-month period, measured from the date coverage is lost.
  2. The Board of Trustees terminates a particular coverage for all participants of the Plan. If Coverage is changed or eliminated, persons on COBRA only have the right to choose among the options offered to similarly situated non-COBRA beneficiaries;
    For example, if the Trustees were to terminate an HMO contract under which you were covered under COBRA, and another HMO was offered to all other Plan participants in the canceled HMO, you would be allowed to enroll in the replacement HMO.
  3. You request that your COBRA coverage be canceled. If you request termination, the coverage will generally end on the first day of the month following completion of a 30-day period beginning on the date the Administrative Office received your written notice. For example, if they received your letter on May 15, the 30-day period would end on June 15, and the coverage would end July 1;
  4. If your COBRA premium is not paid in a timely manner, your coverage will be canceled;
  5. The date on which the qualified beneficiary first becomes, after the date of election, covered under any other group health plan (as an employee or otherwise) which health plan does not contain any exclusion or limitation with respect to any pre-existing condition of such beneficiary. Note that a qualified beneficiary may not be denied the right to elect COBRA coverage because they are covered under another group health plan at the time they make their COBRA election;
  6. You become entitled to Medicare benefits after COBRA coverage has been elected;
  7. You are no longer disabled.  If a qualified beneficiary is determined to no longer be disabled under the Social Security Act before the end of the 29-month maximum coverage period, COBRA coverage may be terminated for the first month that begins more than 30 days after such determination is made;
  8. The signatory Employers to the Plan no longer provide group health coverage benefits to any of its Employees;
  9. The Plan is terminated.

Cost of Continuation Coverage

The cost of continuation coverage is based on the medical plan (Kaiser, PacifiCare, or Indemnity Plan) in which you are enrolled as of the date of the qualifying event. You also have the opportunity to choose between "Basic Coverage" (also referred to as "core-only" coverage) or the whole plan of benefits ("core-plus") with the exception of life insurance.

The premium (what you pay) for disabled qualified participants may be 150% of the benefit Plan cost during the 19th through 29th months of their coverage. You also have the opportunity to choose between "Basic Coverage" (core-only) or the whole plan of benefits ("core-plus").

Basic coverage provides hospital/medical benefits (under the plan selected) and prescription drug benefits. Alternately, you can choose "core-plus" which adds benefits for dental and vision care. The benefits provided on all continuation coverage is as explained in this booklet.

You should write or phone the Administrative Office to receive a copy of the cost sheet, which provides the continuation rates that apply to you. The phone number and address are shown in the section titled "Summary Plan Description General Info" in the front of this booklet.

How COBRA Coverage Works - In Some Examples

Example 1:
John Q. participates in the group health plan maintained by the ABC Co. John is fired for a reason other than gross misconduct and his health coverage is terminated. John may elect and pay for COBRA health continuation coverage for a maximum of 18 months.

Example 2:
David P. has health coverage through his wife’s plan sponsored by the XYZ Co. David loses his health coverage when he and his wife become divorced. David may elect and pay for COBRA health continuation coverage with the plan of his former wife’s employer. Since in this case divorce is the qualifying event under COBRA, David is entitled to a maximum of 36 months of COBRA coverage.

Dependent/Spouse Change or Address Change

Contact the Administrative Office if you change your marital status or if you or your spouse change addresses.
 

 

 

 

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