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Revised April 2017 HRM Benefits

CONSOLIDATED COBRA PROCEDURES

For

DENTAL, HEALTH, VISION

And

HEALTH CARE REIMBURSEMENT ACCOUNT

ADMINISTRATIVE GUIDE

April 2017

CSU COBRA Administrative Guide

California State University

COBRA ADMINISTRATIVE MANUAL

TABLE OF CONTENTS

Section 1 INTRODUCTION PAGE

1.1 Eligibility……………………………………………………………………………………………………… 2

1.2 Coverage…………………………………………………………………………………………………….. 2

1.3 Qualified Beneficiary……………………………………………………………………………………….. 3

1.4 Qualifying Events……………………………………………………………………………………………. 3

Section 2 ADMINISTRATION

2.1 Enrollment…………………………………………………………………………………………………… 4

2.2 Continuation of Enhanced Dental Coverage upon Retirement………………………………………… 4

2.3 Continuation Options for Vision Coverage upon Retirement………………….……………………….. 5

2.4 Responding to Provider Inquiries…………………………………………………………………………. 5

2.5 Disability Extension…………………………………………………………………………………………. 5

2.6 Leave of Absence ………….………………………………………………………………………………. 5

2.7 Adding Dependents………...………………………………………………………………………………. 6

2.8 HIPAA Special Enrollment Periods ……………………………………………………………………… 6

2.9 FlexCash…………………………………………………………………………………………………….. 6

2.10 Health Care Reimbursement Account (HCRA) Continuation………………………………………….. 7

Section 3 COVERAGE PERIOD

3.1 18-Month Coverage………………………………………………………………………………………… 7

3.2 29-Month Disability Extension…………………………………………………………………………….. 7

3.3 36-Month Coverage………………………………………………………………………………………… 8

3.4 Multiple Qualifying Events………………………………………………………………………………… 8

3.5 Additional Continuation of Coverage Rights for Certain Qualified Beneficiaries……………………. 9

Section 4 NOTICES

4.1 Notice Requirements……………………………………………………………………………………….. 9

4.2 Initial Notice………………………………………………………………………………………………….. 9

4.3 Qualifying Event Notice…………………………………………………………………………………….. 10

4.4 Employee Responsibility……………………………………………………………………………………. 10

4.5 Ineligibility Notice…………………………………………………………………………………………. 10

4.6 Early Termination Notice……………………………………………………………………………………. 10

Section 5 ELECTION PERIOD

5.1 Timely Election…………………………………………………………………….……………….……….. 10

5.2 Making a COBRA Election………………………………………………………………………..…….… 11

5.3 Failure to Make a Timely Election……………………………………………………………………..…. 11

5.4 Waiver of Rights……………………………………………………………………………………………. 11

5.5 Waiver of Rights Revocation………………………………………………………………………………. 11

Section 6 MEDICARE ENTITLEMENT

6.1 Explanation of Medicare……………………………………………………………………………………. 12

6.2 Eligible versus Entitled…………………………………………………………………………………..…. 12

Section 7 FAMILY AND MEDICAL LEAVE ACT (FMLA) …………………………………………….………................. 12

Section 8 TERMINATION OF COVERAGE ……………………………………………………………............................. 13

Section 9 COBRA PREMIUMS

9.1 Administrative Fee..……………………………………………………………………………….….......... 14

9.2 Grace Period………………………………………………………………………………………………… 14

9.3 Deficient Premium Payments………………………………………………………………………………. 14

9.4 Late Payments…………………………………………………………………………………………… … 14

9.5 Acceptance of Payments…………………………………………………………………………………… 15

CSU COBRA Administrative Guide

9.6 COBRA Enrollment Processing…………………………………………………………………………….15

9.7 COBRA Premiums…………………………………………………………………………………………...15

Section 10 CONVERSION PRIVILEGE ………………………….………………………….............................................. 15

Section 11 QUICK REFERENCE CHARTS

11.1 COBRA Continuation Coverage Periods………………………………………………………………….. 15

11.2 Sending Qualifying Event Notices…………………………………………………………………………. 16

11.3 Timelines for Notification, Election and Premium Payments…………………………………………… 16

Appendices

MODEL NOTICES

Appendix A Initial (General) Notice

Appendix B Qualifying Event (Election) Notice

Appendix C Notice of Unavailability

Appendix D COBRA Forms

Appendix E COBRA Rates

CSU COBRA Administrative Guide

Revised April 2017

THE CALIFORNIA STATE UNIVERSITY

COBRA ADMINISTRATIVE GUIDE

(Health, Dental, Vision and Health Care Reimbursement Account)

This document is intended to serve as a guide to assist campuses in understanding and handling problems in

the administration of COBRA continuation coverage. This document supersedes any previous communications.

SECTION 1 - INTRODUCTION

The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 was enacted into law on April 7, 1986.

Certain changes to COBRA have been made through amendments contained in the Tax Reform Act of 1986

(TRA), the Technical and Miscellaneous Revenue Act of 1988 (TAMRA), the Revenue Reconciliation Act of

1989 (REVRA), the Omnibus Budget Reconciliation Act of 1990 (OBRA), the Small Business Job Protection Act

of 1996 (SBJPA), and the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Internal

Revenue Service (IRS) issued a revised and updated set of Proposed Regulations on January 7, 1998. On

February 2, 1999, the IRS issued the Final Regulations based upon the Proposed Regulations interpreting the

COBRA continuation coverage requirements published in June 1987 and January 1998. The Final Regulations

represent a restatement of the 1987 proposed regulations and are effective as of January 1, 2000. The Final

Regulations apply with respect to “qualifying events” occurring in plan years beginning on or after January 1,

2000. On February 17, 2009, President Obama signed the American Recovery and Reinvestment Act of 2009

(ARRA) which provided certain eligible individuals with a subsidy of 65% of the premium. Due to statutory sunset

of ARRA the subsidy for qualified terminations ended after May 31, 2010. COBRA applies to government

employers such as the California State University through the Public Health Service Act.

Roles and Responsibilities

Designated Benefits Representatives

Within the California State University system (CSU), each campus, including the Chancellor’s Office is an

appointing authority. Therefore, the designated Benefits Representative(s) is the primary point of contact for

active, retiring and separating employees. Responsibilities include notifying new and separating employees (and

eligible dependents) of their COBRA rights; advising eligible employees (and their dependents) of the COBRA

effective date of coverage, plan options and COBRA enrollment costs based on employee category; distributing

appropriate COBRA notices in a timely manner and providing mailing instructions for COBRA election

documents.

Human Resources Management

The Human Resources Management (HRM) staff, located in the Chancellor’s Office, is responsible for the

development and communication of CSU policies and procedures, in accordance with federal and state laws, as

well as applicable collective bargaining agreements.

Within HRM, the Benefits staff is responsible for the overall administration of COBRA, which includes providing

campuses with consistent and accurate COBRA law interpretation, applicable COBRA communications and

templates, and providing guidance with COBRA issues that require HRM resolutions. Campus inquiries from

Benefits Representatives regarding CSU COBRA Administration can be forwarded to:

BenefitsInsider@calstate.edu.

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Benefits Carriers and/or Designated COBRA Third Party Administrators

Each benefits carrier that provides COBRA coverage is responsible for providing a seamless transition from

active to COBRA coverage for eligible employees and their dependents by processing the COBRA enrollment in

a timely manner, forwarding monthly payment notifications, resolving customer service issues and paying claims

appropriately. Additional information regarding benefits carriers are provided in a later section of this document.

1.1 Eligibility

Generally, COBRA provides that virtually all employers who sponsor group health plans must permit covered

individuals who lose coverage under the plan(s) as a result of certain “qualifying events” set forth in COBRA to

elect to continue their coverage under the plan(s) for a prescribed period of time on a self-pay basis.

The following three elements are necessary to trigger COBRA eligibility:

1. The individual must be a “qualified beneficiary” (see Section 1.3);

2. The individual must experience a “qualifying event” (see Section 1.4); and

3. The individual must lose group coverage as a result of that qualifying event, within a certain time period.

Qualified beneficiaries are eligible to continue health, dental and vision coverage for up to 18, 29 or 36 months,

depending on the qualifying event. Employees enrolled in the Health Care Reimbursement Account (HCRA)

plan may continue participation only until the end of the plan year, if certain criteria are met (see Section 2.10).

Benefits eligible retirees who retire within 120 days of separation continue health and dental coverage into

retirement. Upon retirement, the dental coverage for CSU employees is reduced to the Basic level of coverage,

which, according to COBRA regulations, constitutes a “loss of coverage.” Consequently, eligible CSU retirees

should be offered COBRA continuation for dental coverage at the level they were covered under prior to

retirement, if dental coverage was beyond the Basic level (Enhanced Level I or Enhanced Level II).

Vision coverage is discontinued at the time of retirement and the employee should be offered the following

options from which to choose enrollment: 1) COBRA continuation coverage for vision for 18 months; 2)

Enrollment in the CSU Retiree Voluntary Vision Plan if applicable. If the employee opts to enroll in COBRA

continuation for vision coverage (on a self-pay basis), enrollment in the CSU Retiree Voluntary Vision Plan can

be elected within 60 days of losing the COBRA coverage, or during any future open enrollment (with premiums

paid by the retiree).

Faculty Early Retirement Program (FERP) employees may continue health and enhanced dental coverage into

retirement, but vision coverage is continued on a 12-month one-time payment basis with reemployment. If at the

end of the 12-month appointment a FERP employee is not reappointed or completes the five (5) year FERP

assignment, he/she has COBRA vision and enhanced dental continuation rights for up to 18 months (or can

enroll in the CSU Voluntary Retiree Vision Plan).

1.2 Coverage

Individuals who elect COBRA coverage must be provided with the same coverage that they received

prior to the qualifying event. Qualified beneficiaries must be treated the same as “similarly situated” non-COBRA

beneficiaries with respect to coverage options, benefit limitations, and conversion rights available under the

group health plan.

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Revised April 2017

COBRA coverage consists of two parts: Core coverage is health coverage and non-core coverage refers to

dental, vision and Health Care Reimbursement Account (HCRA). Active and eligible employees have the option

of enrolling in core and/or non-core coverage, as do COBRA participants. They may continue all health, dental,

vision and/or HCRA coverage they have at the time of the "qualifying event," or they may continue only part of

their coverage (i.e., health only, dental only, vision only, or HCRA only).

COBRA participants may not enroll in a plan they do not have coverage under at the time of the qualifying event.

COBRA participants must continue coverage with their current carriers until the annual open enrollment period,

at which time they may make changes, unless they experience a HIPAA special enrollment or a change in status

event that allows for a mid-year change. Employees (qualified beneficiaries) with HMO health plans or prepaid

(DHMO) dental coverage may change to a different carrier before the next open enrollment period if they move

out of the plan’s service areas. They may enroll in any plan(s) that will extend coverage to the new location.

Under COBRA, the employee (qualified beneficiary) remains in the group plan without any change in benefits.

The current evidence of coverage booklet applies and any future changes in benefit provisions or premium rates

apply to COBRA participants, as well as to regular participants.

1.3 Qualified Beneficiary

A "qualified beneficiary"(QB) is any individual (i.e., an employee and his/her spouse or domestic partner and

children) covered under the group health plan(s) on the day before the “qualifying event” (see Section 1.4). The

Health Insurance Portability and Accountability Act (HIPAA) amended COBRA to provide that “children who are

born to an employee or placed for adoption with an employee during the period in which the employee is

receiving COBRA coverage will henceforth become qualified beneficiaries” even though they were not covered

under the plan on the day before the qualifying event.

For purposes of the CSU plans (dental, vision, Health Care Reimbursement Account (HCRA)) and CalPERS

health plans, domestic partners who are members of a “registered domestic partnership” as defined by California

law, and registered through the California Secretary of State process, and their eligible children covered under

any of the CSU and CalPERS group health plans at the time of a “qualifying event” are considered qualified

beneficiaries and should be offered COBRA continuation coverage when qualifying events occur. Effective

January 1, 2005, pursuant to Assembly Bill (AB) 205, eligible domestic partnerships include a “union other than

marriage validly formed in another jurisdiction that is substantially equivalent to a registered domestic

partnership in California.”

Qualified beneficiaries have independent election rights.

1.4 Qualifying Events

"Qualifying events" are certain types of events that would cause an individual to lose coverage under the group

health plan(s). The qualifying events with respect to an employee who is a qualified beneficiary are:

1. Termination of employment (for reasons other than gross misconduct); and

2. Reduction in the employee’s hours of employment.

Qualifying events with respect to an employee’s spouse or domestic partner, or children who are qualified

beneficiaries are:

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1. Termination of the employee’s employment (for reason’s other than gross misconduct);

2. Reduction in the employee’s hours of employment;

3. Death of the employee;

4. Divorce or legal separation or dissolution of domestic partnership from covered employee;

5. The employee’s entitlement to Medicare; or

6. A child’s loss of dependent status.

SECTION 2 - ADMINISTRATION

2.1 Enrollment

Enrollment instructions for COBRA continuation coverage may vary by plan. If an individual elects to continue

dental and/or vision coverage, follow the carrier's COBRA enrollment instructions; for health coverage, follow

CalPERS’ instructions; and for HCRA, follow CSU guidelines.

For continuation coverage in a CalPERS health plan, eligible employees and/or qualified beneficiaries must

complete a CalPERS “Group Continuation Coverage" form (HBD-85) and an election form. For specific

information and obtaining the forms, refer to CalPERS website.

The dental and vision carriers provide campus staff with specific COBRA enrollment procedures and forms.

COBRA enrollment forms for the Health Care Reimbursement Account (HCRA) are provided by the Chancellor’s

Office, Human Resources Management. COBRA premiums for dental and vision are submitted to the

carriers/providers. HCRA premiums are submitted directly to the Third Party Administrator. The dental, vision

and HCRA providers will then contact the COBRA enrollees directly. Thereafter, COBRA premiums are to be

submitted with the billing statement supplied by the carrier/provider.

2.2 Continuation of Enhanced Dental Coverage upon Retirement

Upon retirement from the CSU, employees who were enrolled in enhanced dental plan coverage during active

employment can elect to maintain dental coverage at an enhanced level through COBRA for an 18-month

period. However, the retirement must be in accordance with Government Code Section 22760, and the COBRA

election must be made within 60 days of the loss of coverage date, or from the date of the COBRA Qualifying

Event Notification, whichever is later. The retiree is responsible for paying the full amount of the monthly dental

premium plus the 2% administrative fee, in lieu of receiving CSU-paid basic dental coverage. Please note: A

retiree cannot be enrolled in both CSU COBRA for dental and the CSU basic dental plan at the same time.

Enrollment in COBRA for the 18-month period does not disqualify the retiree or his/her eligible dependents from

enrolling in the basic retirement dental benefit at a later date. The retiree can cancel COBRA at any time during

the 18-month period, and elect to enroll in basic dental coverage. If the retiree dies while on COBRA, his/her

survivors can be enrolled in basic coverage at the time of death, or during any subsequent enrollment period, if

the survivor does not choose COBRA continuation. If, however, the survivor wishes to remain enrolled in the

enhanced plan, the survivor would be eligible for COBRA for a period of 36 months minus the period of time

already covered (see Section 3.4). For example, if the retiree died after receiving 10 months of COBRA

coverage for self and spouse and dependents, the survivor, spouse and any covered dependents would be

eligible for the remaining 26 months for a total of 36 months.

At the end of the COBRA eligibility period, the retiree may contact CalPERS to enroll in basic dental coverage.

Enrollment in the basic dental plan can be processed at the end of the COBRA period, or during any subsequent

open enrollment period.

CSU COBRA Administrative Guide

Revised April 2017

2.3 Continuation Options for Vision Coverage upon Retirement

As a result of the different premium rate structures of the CSU Retiree Voluntary Vision Plan and the eighteen

(18) month COBRA option available through the active employee CSU Vision Plan, both options are available to

eligible retiring employees and their qualified dependents. Consequently, these employees can enroll in either

COBRA or the CSU Retiree Voluntary Vision Plan in order to continue vision benefits into retirement. Therefore,

the campus Benefits Office is required to offer both CSU vision insurance coverage options (COBRA and CSU

Retiree Voluntary Vision Plan) to eligible employees, upon retirement.

These options apply also to FERP participants (and qualified dependents) who end the FERP assignment or

whose time base drops below half-time, resulting in loss of vision coverage under the active employees’ Vision

Plan.

If COBRA for vision coverage is chosen and the retiree subsequently exhausts the COBRA enrollment period, or

cancels COBRA coverage, the retiree can opt to enroll in the CSU Retiree Voluntary Vision Plan within 60 days

of loss of coverage or during any subsequent open enrollment.

2.4 Responding to Provider Inquiries

The Plan must respond to provider inquiries (such as a physician, hospital, HMO or pharmacy) in a timely

manner regarding a qualified beneficiary’s coverage status. Upon such an inquiry, the Plan must inform a

provider that the qualified beneficiary for whom coverage has not yet been elected (i.e., during the election

period) is eligible for continuation coverage, but that the coverage has been terminated and will be retroactively

reinstated if the COBRA election is made and paid for within the proper time frame.

2.5 Disability Extension

The employee or dependent also is responsible for notifying the campus of his/her Social Security disability

determination within 60 days of receipt, and prior to the end of the initial 18 month period in order to receive the

extension of COBRA eligibility from 18 months to up to 29 months. Once he/she is no longer disabled, the

campus must be notified within 30 days of final Social Security determination for termination of the COBRA

coverage. The Social Security determination notice should be sent to the carrier and a copy should be placed in

the employee file or COBRA file. Refer to Section 3.2 for additional continuation provisions.

2.6 Leave of Absence

Employees on a leave of absence without pay who have chosen to direct pay benefits and do not return from

leave to a qualifying appointment, may qualify for COBRA coverage. If an employee takes FMLA leave and

does not return to work at the end of the leave, the employee (and the employee’s dependents, if any) will be

entitled to elect COBRA if (1) they were covered under the CSU’s health plans on the day before the FMLA

leave began (or become covered during the FMLA leave); and (2) they will lose health plan coverage because of

the employee’s failure to return to work at the end of the leave. If the employee is on direct pay and a covered

dependent turns 26, the dependent would be eligible for COBRA coverage. The standard COBRA procedures

and timelines would apply. Refer to Section 7 for information on Family Medical Leave (FMLA).

CSU COBRA Administrative Guide

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2.7 Adding Dependents

Qualified beneficiaries must be permitted the same rights during open enrollment periods as similarly situated

(active) employees. During any open enrollment period COBRA participants may enroll family members in the

plan(s) and change the type of coverage they are receiving.

Qualified beneficiaries are permitted to add dependents (even those for whom COBRA was initially declined),

mid-year and at open enrollment, to the same extent active employees are allowed to add dependents. Newly

acquired eligible dependents may be added to COBRA coverage within 60 days of that event, or during a

subsequent open enrollment period. Newly acquired eligible dependents will not be considered qualified

beneficiaries for COBRA purposes unless they are gained through birth, adoption or placement for adoption and

are enrolled within 60 days of the birth, adoption or placement for adoption. Coverage must be the same as the

employee’s (see Section 1.3).

2.8 HIPAA Special Enrollment Periods

The Health Insurance Portability and Accountability Act (HIPAA) requires that group health plans provide special

enrollment periods during which eligible individuals who previously declined coverage (or did not enroll when first

eligible) must be permitted to enroll in the plan. Newly acquired eligible dependents of qualified beneficiaries

enrolled in COBRA may be added to COBRA coverage within 60 days of that event, or during a subsequent

open enrollment period. Coverage must be the same as the qualified beneficiary’s. Specifically, HIPAA requires

that a group health plan must permit the enrollment of a qualified beneficiary’s dependent who previously

declined coverage under the plan if:

1. The qualified beneficiary is enrolled in COBRA;

2. The qualified beneficiary’s dependent was covered under another group health plan at the time

coverage was initially offered; and

3. The dependent lost eligibility for the other coverage (other than for nonpayment of premium) and the

qualified beneficiary requests enrollment for the dependent no later than 60 days after the termination of

the other coverage.

In addition, HIPAA requires that a group health plan must permit the enrollment of new dependents if a qualified

beneficiary gains a dependent through marriage, birth, adoption or placement for adoption, and the request for

enrollment is within 60 days of the date the individual became a dependent.

Coverage for new dependent children will be retroactive to the date of birth, adoption, or placement for adoption.

For all other events, coverage will be effective on the first day of the month following enrollment.

Note, COBRA regulations specifically clarify that the HIPAA special enrollment rules do not operate to permit an

employee who had declined COBRA continuation coverage to enroll after the COBRA election period has

expired.

2.9 FlexCash

Employees currently enrolled in and receiving FlexCash in lieu of health and/or dental coverage are ineligible for

COBRA continuation coverage for that particular plan.

CSU COBRA Administrative Guide

Revised April 2017

2.10 Health Care Reimbursement Account (HCRA) Continuation

An employee qualified beneficiary (QB) may be able to continue participation in the Health Care Reimbursement

Account (HCRA) for the remainder of the current plan year if there is an account balance at the time of the

qualifying event (with the exception of employees on FML).

Employee QBs who elect to continue HCRA participation make payments on an after-tax basis, and pay an

additional 2% administrative fee (employees on FML do not pay the 2% fee). The employee QBs will have

access to his/her HCRA account balance for the remainder of the year. If the employee does not qualify to

continue participation in HCRA, the account balance may be forfeited. Note that employees can continue to

submit claims incurred prior to the date that their participation in the HCRA plan ended. Eligibility for

participation in the HCRA plan ceases at the end of the plan year.

If an employee dies or gets divorced while enrolled in the HCRA plan, eligible dependents may participate in the

HCRA plan and submit claims for their own unreimbursed medical expenses, or for expenses incurred by the

employee prior to death, through the end of the plan year.

If the COBRA participant is also a Debit Card participant, access to the Debit Card will continue so long as the

monthly COBRA payments are made on a timely basis.

SECTION 3 - COVERAGE PERIOD

3.1 18-Month Coverage

The following events qualify an employee and/or family member(s) enrolled in Health, Dental and Vision for up to

18 months of continued coverage:

1. Termination of employment for reasons other than gross misconduct.

Termination includes voluntary

or involuntary termination if there is a loss of coverage. Termination also includes retirement.

2. Reduction of hours that results in the loss of eligibility (e.g., employed less than half-time or less than

.4 for employees who are benefits eligible under Assembly Bill (AB)211 rules, including a strike,

walkout or layoff). This also includes employees who subsequently lose Affordable Care Act (ACA)

eligibility for health coverage.

Continued participation in HCRA is allowed only until the end of the plan year, if certain criteria are met (see

Section 3).

“Gross Misconduct" has not been defined in the federal legislation, and CalPERS has no additional guidelines, making each agency

responsible for the administration of this issue. Employees who are denied COBRA continuation coverage may appeal the decision

through the federal Department of Health and Human Services. In the absence of guidelines, denial of continuation coverage for gross

misconduct should only be applied in those situations that the CSU has the right to prosecute a terminated employee for criminal

misconduct.

3.2 29-Month Disability Extension

Certain qualified individuals can extend COBRA continuation coverage due to a disability. If a qualified

beneficiary is determined by the Social Security Administration (pursuant to Title II or Title XVI of the Social

Security Administration) to have been disabled on the date of termination or reduction in hours, or within the first

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60 days of continuation coverage due to such event, continuation coverage may be provided for up to 29

months, instead of 18 months. This extension does not apply to HCRA enrollment.

A disability extension may be elected independently for each qualified beneficiary (the disabled person or any

family member). To qualify for the additional 11 months of coverage, the carrier must be notified within 60 days

of the date Social Security made the disability determination and before the end of the initial 18-month period. If

Social Security makes a determination of disability prior to the date employment ends or hours are reduced, then

CSU must be notified within 60 days of the date employment ends or hours are reduced. CSU (or the carrier)

must be notified within 30 days if the Social Security disability determination expires.

Individuals who qualify for the disability extension, but who are not part of the family unit that includes the

disabled person, may continue to be charged 102% of the applicable group rate. (This situation might occur, for

example, if there is a divorce or legal separation, or if the disabled person does not elect to continue coverage

for the additional 11-month period.) Individuals who qualify for the disability extension, who are part of the family

unit that includes the disabled person, may be charged up to 150% of the applicable group rate for the 19

through the 29

month. The cost of coverage during the 19

through 29

month extension period will be 150%

of the monthly group cost. If a second qualifying event occurs during the disability extension, the 30th through

36th month should be charged at 102%.

3.3 36-Month Coverage

The following events qualify eligible qualified beneficiaries enrolled in the Health, Dental and/or Vision plans for

continued coverage for up to a maximum of 36 months:

1. Death of covered employee/retiree;

2.Divorce or legal separation

of a spouse (or dissolution of domestic partnership) from a covered

employee/retiree;

3.Termination of a child's dependent status (e.g., dependent reaches age 26);

4. Covered employee/retiree's entitlement to Medicare (Health Only); or

5.Moving out of the household

(Health Only).

Federal legislation identifies a "Legal Separation" as a qualifying event, and COBRA coverage must be offered. The "legal separation"

process is handled through judicial channels. For purposes of dental and vision coverage only, employees who separate from their

spouses (or “move out of the household”) without filing for "legal separation" status through the court, and those who file for divorce in

lieu of a "legal separation" are not eligible for COBRA continuation coverage until the divorce (if any) becomes final, and then only if

they are enrolled in the plan on the date of divorce. However, if a spouse is dropped from the Plan in anticipation of divorce, the

spouse will be eligible for COBRA when the divorce becomes final. Although not a legal requirement, CalPERS recognizes “moving

out of the household” as a qualifying event for purposes of continued health coverage. This option is not available for participants in the

CSU dental, vision and HCRA plans.

3.4 Multiple Qualifying Events

If a qualifying event occurs that triggers an 18-month continuation coverage period (i.e., a termination of

employment, for reasons other than gross misconduct, or a reduction in hours) and then a second qualifying

event occurs during that 18 month period, the maximum continuation coverage period will be extended to 36

months from the date of the first qualifying event. This extension applies only to a qualified beneficiary who

became a qualified beneficiary as a result of the first qualifying event and was still covered under the group

health plan when the second qualifying event occurred.

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Each qualified beneficiary may make a separate COBRA election. For example, an employee may elect not to

continue coverage but the spouse and/or dependent children may elect to continue coverage. Elections on

behalf of minor children are made by a parent or guardian. A spouse or legal representative can make an

election on behalf of a qualified beneficiary if the beneficiary becomes incapacitated or dies prior to election.

3.5 Additional Continuation of Coverage Rights for Certain Qualified Beneficiaries (for California only)

Assembly Bill (AB) 1401 (Cal-COBRA) permits specified individuals who begin continuation coverage on or after

January 1, 2003, and who subsequently exhaust all available Federal COBRA continuation coverage, the

opportunity to extend their coverage term up to 36 months (includes all prior COBRA coverage), regardless of

the nature of the initial COBRA qualifying event. The provisions of AB 1401 apply to health coverage only (not

dental or vision). Premiums are 110% of the corresponding group rate.

An individual who terminated employment may continue coverage for 18 months under Federal COBRA (at a

cost of 102%), and then may request continued coverage for an additional 18 months (at a cost of 110%) under

AB 1401. An individual who meets the Social Security Administration’s definition of disabled (which entitles the

disabled individual to up to 29 months of continuation coverage) is eligible for an additional seven months of

coverage under AB 1401. The coverage cost would be 102% for 18 months of coverage under Federal COBRA,

150% during the disability extension period (months 19 through 29) and 110% for the additional seven months of

coverage under AB 1401.

Participants must apply for the extension directly with the insurance carrier or health plan prior to the expiration

of their Federal COBRA coverage. Participants should be referred to CalPERS or their health plan for additional

information.

SECTION 4 - NOTICES

4.1 Notice Requirements

COBRA contains six separate notice requirements. Five of the six notices are discussed below. The sixth

notice, Employer Notice to Plan Administrator, is not currently applicable to the California State University

(CSU). CSU must provide written (“initial”) notice of COBRA rights to each covered employee and his or her

spouse or domestic partner, if any, when coverage under a particular plan first commences. A second notice

(“qualifying event”) of COBRA rights must be furnished to all qualified beneficiaries at the time a qualifying event

occurs. In addition, other notices may be required as outlined below. The Health, Dental, Vision (Evidence of

Coverage booklets) and the Health Care Reimbursement Account (HCRA) Administrative Guide have examples

of COBRA continuation rights. The distribution of this information to employees does not replace the COBRA

notices that must be mailed out by the campus.

4.2 Initial Notice

The initial notice of COBRA rights for new hires and their covered dependents must be mailed first class by the

campus to the employees' last known address (see the sample “Model Statement” in the Appendix A). The

notice must be addressed to both the employee and his/her spouse or domestic partner and must be provided

within 90 days after coverage begins. If the spouse, or domestic partner and/or dependents become covered at

a later date than the employee, a separate notice must be mailed to the spouse (or domestic partner or

dependent(s)) within 90 days after the coverage begins.

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4.3 Qualifying Event (Election) Notice

Upon being notified of a qualifying event, the campus must provide a second COBRA notice (a “qualifying event”

notice) to qualified beneficiaries who lost (or will lose) coverage as a result of the qualifying event. This notice

requirement is distinct from the initial COBRA notice requirement. Enrollees (employee and/or spouse or

domestic partner and/or dependents) who are eligible to elect COBRA coverage because of a qualifying event

must be notified by first class mail, explaining possible rights and responsibilities, by sending the Qualifying

Event notice to their last known address within 14 days of the qualifying event. See the “Qualifying Event

(Election) Notice” (in Appendix B).

If it is determined that the spouse does not reside at the employee’s last known address, good faith compliance

can be achieved by sending a separate first-class mail notice to the spouse or domestic partner at his/her last

known address.

4.4 Responsibility of Employee and Dependent(s) to Provide Notice

It is the responsibility of the employee or covered dependent to notify the campus Benefits Representative within

60 days of a divorce, legal separation, dissolution of domestic partnership, or termination of a child's eligibility.

It is important for campuses to retain sufficient documentation regarding the procedures and actions taken to

comply with notice requirements. In the event of a lawsuit by a qualified beneficiary claiming not to have

received a COBRA notice or COBRA coverage, it may be necessary, in order to avoid liability, to prove that the

notices were provided. Failure to provide the required COBRA notices in a timely manner may result in

imposition of statutory penalties and an award of damages.

4.5 Ineligibility Notice

If the campus receives a notice from an individual who believes he or she is eligible for COBRA (or a COBRA

extension), but is not eligible, the campus must send the individual written notice that the individual is not

eligible. The notice should be mailed first class. The notice must be provided within 14 days of the individual

request for COBRA and must explain that COBRA is not available and why. See the “Notice of Unavailability” in

Section 11.3.

4.6 Early Termination Notice

If COBRA coverage will end early, the affected qualified beneficiaries must be notified. This notification will be

handled by the insurance carriers, dental COBRA administrator, HMOs and HCRA claims administrator.

SECTION 5 - ELECTION PERIOD

5.1 Timely Election

After notification following a qualifying event, the eligible employee and/or spouse/dependent will have 60 days

to elect COBRA continuation coverage. The 60-day election period is measured from the later of the loss of

coverage date, or from the date that the COBRA Qualifying Event Notice is mailed (i.e., postmark date).

CSU COBRA Administrative Guide

Revised April 2017

The Plan must also accept a timely election (and/or a premium payment) on behalf of a qualified beneficiary

from a provider, if received, in order to maintain the coverage. Elections also may be made by a third party (e.g.,

in order to comply with a court order).

5.2 Making a COBRA Election

COBRA regulations provide that a qualified beneficiary’s election is treated as “made” on the date that it is

mailed to the campus. Accordingly, an election received after the 60-day election period, but which is

postmarked (or otherwise sent) on or before the 60

day, would be considered timely. The enrollee will then

have 45 days from the election date to submit premium payment (see Section 9).

Each qualified beneficiary (including a child who is born to or placed for adoption with a covered employee

during the period of COBRA continuation coverage) must be offered the opportunity to make an independent

election to receive COBRA continuation coverage. An employee and his/her spouse or domestic partner can

elect COBRA coverage on behalf of other qualified family members. However, they cannot reject or waive

COBRA coverage on behalf of another qualified beneficiary. The only exception is for minor children, whose

elections to either continue or reject coverage can be made on their behalves by their parents or legal guardians

(regardless of whether the parent or guardian is a qualified beneficiary).

A legal representative (or a qualified beneficiary’s estate) can make an election for an incapacitated qualified

beneficiary. If a covered employee or spouse or domestic partner elects COBRA coverage

and the election does not specify whether the election is for self-only coverage, the election will be deemed to

include an election for all other qualified beneficiaries with respect to that qualifying event.

5.3 Failure to Make a Timely Election

A qualified beneficiary who fails to elect continuation coverage within the 60-day election period ceases to be a

qualified beneficiary once the election period expires and is no longer eligible to elect COBRA coverage with

respect to that particular qualifying event. Once qualified beneficiary status is lost, reinstatement is not allowed.

5.4 Waiver of Rights

Qualified beneficiaries are free to waive or reject COBRA continuation coverage. For any individual who decides

not to elect COBRA, CSU does not require evidence of waiver. However, if a written waiver is submitted, it is

considered to be made on the date it is sent to the employer, as applicable. The campus should retain a written

waiver as proof that continuation coverage was in fact rejected.

5.5 Waiver of Rights Revocation

COBRA regulations provide that, prior to the expiration of the 60-day election period, a qualified beneficiary who

has waived COBRA coverage (e.g., sent a letter to the campus stating that he or she does not want COBRA

coverage) has the right to revoke that waiver. A revocation of a waiver is an election of continuation coverage.

The revocation of the waiver and the subsequent election of COBRA coverage must be made within the 60-day

election period. If a qualified beneficiary either elects, or waives COBRA coverage before the 60-day election

period expires, he or she is entitled to change the election or revoke the waiver of COBRA continuation

coverage at any time during the remainder of the 60-day election period. Waivers and revocation of waivers of

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Revised April 2017

COBRA coverage are treated as made on the date that they are sent to the campus. COBRA coverage will be

effective back to the date of the loss of coverage if a waiver is properly revoked.

SECTION 6 - MEDICARE ENTITLEMENT

6.1 Explanation of Medicare

Medicare is a federally funded health insurance program authorized by Title XVIII of the Social Security Act [42

USC §§ 1395-1395cc) established to ensure that covered individuals receive certain levels of medical

assistance. It provides health insurance coverage to individuals age 65 and older, those who are disabled but

have not yet attained age 65, and those who suffer from end-stage renal disease (ESRD). The Medicare

program is administered by the Center for Medicare and Medicaid Services (CMS) of the U.S. Department of

Health and Human Services (HHS).

6.2 Eligible Versus Entitled

Medicare entitlement can affect an individual’s eligibility for COBRA coverage and the duration of coverage. It is

important to distinguish between whether an employee or other qualified beneficiary is entitled to Medicare or

merely eligible for Medicare. Eligibility for Medicare will not affect the COBRA rights of covered employees and

their family members. This is because COBRA specifically requires that an employee must be entitled to

Medicare, not merely eligible for Medicare, to trigger the COBRA rights of his or her family members.

Additionally, COBRA requires that a qualified beneficiary must be entitled to, not merely eligible for Medicare, in

order for continuation coverage to be terminated before the statutorily prescribed COBRA period expires.

COBRA Regulations state that a qualified beneficiary becomes entitled to Medicare benefits upon the effective

date of enrollment in either Part A or Part B of Medicare, whichever occurs earlier. Regulations also note that

merely being eligible to enroll in Medicare does not constitute being entitled to Medicare benefits

SECTION 7 - FAMILY AND MEDICAL LEAVE ACT (FMLA)

The Family and Medical Leave Act (FMLA) requires CSU to offer up to 12 weeks (and in some cases up to 26

weeks) of paid or unpaid leave in a specified 12 month period to eligible employees for specified purposes.

During an FMLA leave, health care coverage must be continued at the same level and under the conditions

coverage would have been provided if the employee had continued in employment continuously for the duration

of the leave, at active employee rates. IRS regulations provide that the taking of FMLA leave is not itself a

COBRA qualifying event. Instead, the qualifying event occurs on the last day of the FMLA leave if the employee

on FMLA leave does not return to work at the end of the FMLA leave and loses coverage under the group health

plan as a result of that failure to return, or the date that the employee informs CSU that he/she will not return to

work, if earlier.

Please note: Active, benefits eligible CSU employees would not lose health, dental or vision coverage due to becoming

eligible for Medicare while employed. While a Medicare-eligible employee is actively working, coverage in CalPERS

basic health coverage, CSU dental coverage (level based on CBID) and CSU vision coverage remains intact as long as the

employee delays Medicare Part B enrollment until retirement.

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Regulations provide that COBRA cannot be contingent on payment by the employee of group health plan

premiums due for the period of FMLA leave.

Regulations also provide that any lapse of coverage during FMLA leave is disregarded for purposes of

determining if a COBRA qualifying event occurs on the last day of the leave. No

qualifying event occurs if, during the FMLA leave, CSU eliminates group health coverage for a particular

employee’s classification, or employee category.

Upon notification that an employee will not return to work upon expiration of the FMLA leave, the COBRA

qualifying event (election) notice should be provided.

SECTION 8 - TERMINATION OF COVERAGE

COBRA coverage for health, dental and/or vision will cease if one of the following events occurs prior to the

expiration of the 18, 29 or 36 month continuation period:

1. Failure to pay required premiums on time (e.g., within the monthly 30 day grace period).

2. Termination of the CSU-provided health, dental and/or vision plans for all employees.

3. Becoming entitled to Medicare benefits (Health Benefits only).

4. Coverage is subsequently obtained under another group plan (as an employee or dependent) provided the

plan does not contain any exclusion or limitation with respect to pre-existing conditions that affect the

covered individual. If the new plan excludes coverage for a pre-existing condition, the beneficiary may

continue the COBRA coverage under the prior plan until such time as the exclusion or limitation no longer

applies (subject to normal COBRA maximum periods).

5. The individual extended coverage for up to 29 months due to disability and there has been a final

determination that the individual is no longer disabled. Note: Federal law requires an individual to notify the

plan administrator within 30 days of any final determination that he/she is no longer disabled. Coverage will

not be terminated until the first of the month following the date that is 30 days after the individual notifies the

plan administrator of the Social Security determination.

If the individual has other coverage (including group health insurance, individual coverage, or Medicare) at

the time of the qualifying event, or before COBRA is elected, COBRA must still be offered.

When COBRA continuation coverage is exhausted or terminated, all individuals losing coverage must be

provided with a certification of creditable coverage, in accordance with the Health Insurance Portability and

Accountability Act (HIPAA). This function is handled by the individual benefit carriers.

For the Health Care Reimbursement Account (HCRA) plan, participation will be terminated at the end of the plan

year.

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SECTION 9 - COBRA PREMIUMS

9.1 Administrative Fee

Premium rates for COBRA continuation coverage vary from 102% to 150% depending on the qualifying event.

Participants continuing coverage under COBRA must pay the full COBRA premium; there is no CSU employer

contribution toward this continuation coverage. Health, dental and vision COBRA premiums are distributed by

CSU, Chancellor's Office, Systemwide Human Resources via an HR/Benefits Technical Letter. COBRA rates

can be located at: http://csyou.calstate.edu. HCRA premiums are equivalent to the monthly contribution amount

made while the individual was actively employed plus 2%.

Generally, COBRA premiums are 102% of the group premium. However, individuals who are

disabled and continue coverage for 29 months pay 102% for the first 18 months, and 150% for

the next 11 months. If only non-disabled individuals continue coverage, the premium cannot exceed 102% for

the extension period. Premiums are 110% of the group premium for coverage extended under Cal COBRA.

COBRA premiums must be paid so coverage is continuous after termination from the group coverage; therefore,

the initial payment must include retroactive premium amounts. The initial COBRA premium payment, including

any retroactive amounts, must be paid in full within 45 days of the election to continue coverage. Subsequent

monthly payments are due to the carrier by the 1st of each month. A 30 day grace period must be provided.

9.2 Grace Period

COBRA provides for two grace periods within which COBRA premiums must be paid. In general, the initial

premium payment must be made within 45 days of the COBRA election, and all other premium payments must

be made within 30 days after the first day of the coverage period to which they relate.

Premium payment is not required for any period of COBRA coverage earlier than 45 days after the date of the

election. The initial grace period applies to premium due for the periods of coverage prior to the date of the

election. At that time, several months’ premiums could be due and outstanding. If these payments are not made

by the 45

day, coverage may be terminated and need not be subject to reinstatement. If payment is made

within the 45 day grace period, coverage must be restored retroactively to the date coverage was lost.

9.3 Deficient Premium Payments

There are specific rules regarding a plan’s obligations when a premium payment is deficient by an amount that is

“not significantly less” than the amount due. Under these rules, the plan must treat the deficient payment as

satisfying the payment requirement (“paid in full”), or notify the qualified beneficiary of the amount of the

deficiency and furnish him/her with a reasonable amount of time (e.g., 30 days) in which to make payment.

COBRA regulations do not define the term “significant” for purposes of this rule; however, it is suggested that an

amount is not “significant” if it is such a small amount that it would be unreasonable to attribute the deficiency to

anything other than a mistake.

9.4 Late Payments

If the COBRA premium is not paid within the grace period (i.e., 30 days), the plan has the authority to terminate

COBRA coverage. However, if the COBRA payment received is short by an insignificant amount, the plan must

CSU COBRA Administrative Guide

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notify the qualified beneficiary of the deficient amount and grant him or her a period of 30 days to pay the

deficient amount.

9.5 Acceptance of Payments

The Plan must accept a timely premium payment on behalf of a qualified beneficiary in order to maintain the

coverage. Premium payments may also be made by a third party (e.g., in order to comply with a court order).

9.6 COBRA Enrollment Processing

COBRA enrollments are processed manually via each Plan’s enrollment form (dental, vision, HCRA) with the exception of

the CalPERS health plan. Health plan COBRA enrollments are processed via the Pension System Resumption (PSR)

Interface.

9.7 COBRA Premiums

COBRA premiums are updated annually and communicated via an HR/Benefits technical letter. COBRA

premiums can be located at: http://csyou.calstate.edu/Policies/HRPolicies/Forms/Default.aspx and

https://csyou.calstate.edu/tools/hr/employee-benefits/cobra/Pages/cobra.aspx

SECTION 10 - CONVERSION PRIVILEGE

Employees and dependents are entitled to convert to an Individual Conversion Policy instead of COBRA, or

conversion can follow COBRA coverage. In the event the individual does not elect COBRA coverage, he/she

may still apply for conversion to an individual health policy by making an application within 30 days from the date

coverage terminates to ensure continuous coverage. Even if the individual elects COBRA coverage, he/she will

have the option to convert health coverage to an individual policy during the last 180 days of the maximum 18,

29, or 36-month COBRA continuation period, if a conversion policy is available.

When an individual elects individual conversion, he or she forfeits all COBRA continuation rights and may not

elect COBRA continuation later. However, if COBRA continuation coverage is elected, he/she may convert to

an individual policy only after the end of the full COBRA period and, only if he/she maintains the coverage

throughout the COBRA continuation period. All CalPERS health plans offer the conversion policy option;

however, the cost for it will differ from the cost of previous coverage. Premiums are paid directly to the

insurance carrier.

SECTION 11 - QUICK REFERENCE CHARTS

11.1 COBRA Continuation Coverage Periods

Duration

Of Coverage

Individual

Affected

Qualifying Event

18 Months

All Qualified

Beneficiaries

Termination* or Reduction in Hours

* Unless for Gross Misconduct (see section 3.1).

29 Months

All Qualified

Beneficiaries

11-month extension of 18-month Termination or Reduction in Hours coverage

upon certain Social Security determined disabilities

36 Months

Enrolled Spouse or

Domestic Partner and

Dependents

Death of Employee, Divorce, Dissolution of Domestic Partnership, or Legal

Separation of Employee, Entitlement of Employee to Medicare, or Child

Ceasing to be an eligible Dependent

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Continued participation in the Health Care Reimbursement Account plan is permitted through the end of the current plan year only.

Note: There are specific regulations pertaining to continued coverage when employers go bankrupt (for retirees only).

11.2 Sending Qualifying Event Notices

Qualifying Event

Recipient:

Employee

Spouse or

Domestic Partner

Dependent

Retiree

Termination of employee*

Yes

Reduction of hours worked by employee

Yes

Death of employee

Yes

Divorce, Legal Separation, Dissolution of

Domestic Partnership, Moving out of the

household*

Yes

Ceasing to be an eligible dependent

Yes

Medicare entitlement

Yes

* Moving out of the household only applies to health benefits administered by CalPERS.

11.3 COBRA Timelines for Notification, Election and Premium Payments

Notice to CSU

Notice to Qualified

Beneficiaries (QBs)

Election Period

Retroactive Premium

Payment Period

30/60 days

14 days

60 days

45 days

30: The period during which the Benefits

Representative is notified of a Qualifying

Event (usually by the Human Resources

Dept.)

60: Qualified Beneficiaries have 60 days

from a divorce, legal separation, dissolution

of domestic partnership, cessation of

dependency status, or moving out of the

household* to notify the CSU of such event.

The period in which the

CSU must notify QBs of

their COBRA election

rights.

The period during

which QBs may

elect COBRA

coverage (counted

from the later of the

date of the

qualifying event or

notification of

qualifying event).

The period during which

QBs must submit

payment for all COBRA

premiums that are due.

* Moving out of the household only applies to health benefits administered by CalPERS.

APPENDIX A

Initial Notice of COBRA Continuation Coverage Rights

Medical, Dental, Vision and Health Care Reimbursement Account (HCRA) Plan

To: Covered Employee [Spouse/Registered Domestic Partner]

From: EMPLOYER NAME

Date: Insert Date

Introduction

You are receiving this notice because you have recently become covered under a group health plan (the

Plan). This notice contains important information about your right to COBRA continuation coverage, which

is a temporary extension of coverage under the Plan. This notice generally explains COBRA

continuation coverage, when it may become available to you and your family, and what you need

to do to protect the right to receive it.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus

Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can become available to you

when you would otherwise lose your group health coverage. It can also become available to other

members of your family who are covered under the Plan when they would otherwise lose their group

health coverage. For additional information about your rights and obligations under the Plan and under

federal law, you should review the Plan’s Summary Plan Description or contact the Plan Administrator.

What is COBRA Continuation Coverage?

COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end

because of a life event known as a “qualifying event.” Specific qualifying events are listed later in this

notice. After a qualifying event, COBRA continuation coverage must be offered to each person who is a

“qualified beneficiary.” You, your spouse, and your dependent children could become qualified

beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified

beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you are an employee, you will become a qualified beneficiary if you lose your coverage under the Plan

because either one of the following qualifying events happens:

 Your hours of employment are reduced, or

 Your employment ends for any reason other than your gross misconduct.

If you are the spouse or registered domestic partner of an employee, you will become a qualified

beneficiary if you lose your coverage under the Plan because any of the following qualifying events

happens:

 Your spouse or registered domestic partner dies;

 Your spouse’s or registered domestic partner’s hours of employment are reduced;

 Your spouse’s employment ends for any reason other than his or her gross misconduct;

Initial COBRA Notice-HRM:Benefits: 04/2017

APPENDIX A

 Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or

 You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan

because any of the following qualifying events happens:

 The parent-employee dies;

 The parent-employee’s hours of employment are reduced;

 The parent-employee’s employment ends for any reason other than his or her gross

misconduct;

 The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both);

 The parents become divorced or legally separated, or terminate a registered domestic

partnership; or

 The child stops being eligible for coverage under the plan as a “dependent child.”

When is COBRA Coverage Available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator

has been notified that a qualifying event has occurred. When the qualifying event is the end of

employment or reduction of hours of employment, death of the employee, commencement of a proceeding

in bankruptcy with respect to the employer, or the employee's becoming entitled to Medicare benefits

(under Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event.

You Must Give Notice of Some Qualifying Events

For the other qualifying events (divorce or legal separation of the employee and spouse or

termination of the registered domestic partnership of the employee and registered domestic

partner, or a dependent child’s losing eligibility for coverage as a dependent child), you must notify

the Plan Administrator within 60 days after the qualifying event occurs. You must provide this

notice to: add Benefits Office Contact Information.

How is COBRA Coverage Provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation

coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an

independent right to elect COBRA continuation coverage. Covered employees may elect COBRA

continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on

behalf of their children.

Sometimes, filing a proceeding in bankruptcy under title 11 of the United States Code can be

a qualifying event. If a proceeding in bankruptcy is filed with respect to California State

University (CSU), and that bankruptcy results in the loss of coverage of any retired employee

covered under the Plan, the retired employee will become a qualified beneficiary with respect

to the bankruptcy. The retired employee’s spouse or registered domestic partner, surviving

spouse or surviving registered domestic partner, and dependent children will also become

qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan.

Initial COBRA Notice-HRM:Benefits: 04/2017

APPENDIX A

COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the

death of the employee, the employee's becoming entitled to Medicare benefits (under Part A, Part B, or

both), your divorce or legal separation or termination of a registered domestic partnership, or a dependent

child's losing eligibility as a dependent child, COBRA continuation coverage lasts for up to a total of 36

months. When the qualifying event is the end of employment or reduction of the employee's hours of

employment, and the employee became entitled to Medicare benefits less than 18 months before the

qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts

until 36 months after the date of Medicare entitlement. For example, if a covered employee becomes

entitled to Medicare eight (8) months before the date on which employment terminates, COBRA

continuation coverage for the spouse or registered domestic partner and children can last up to 36 months

after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event

(36 months minus 8 months). Otherwise, when the qualifying event is the end of employment or reduction

of the employee’s hours of employment, COBRA continuation coverage generally lasts for only up to a

total of 18 months. There are two ways in which this

18-month period of COBRA continuation coverage can be extended.

Disability extension of 18-month period of continuation coverage

If you or anyone in your family covered under the Plan is determined by the Social Security Administration

to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family may be

entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of

29 months. The disability would have 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.

It is the qualified beneficiary's responsibility to obtain this disability determination from the Social

Security Administration and provide a copy of the determination to the appropriate plan within 60

days after the date of determination and before the original 18- month COBRA eligibility period

expires.

Each qualified beneficiary who has elected continuation coverage will be entitled to the 11- month disability

extension if one of them qualifies. If the qualified beneficiary is determined by SSA to no longer be

disabled, you must notify the Plan of that fact within 30 days after SSA’s determination.

Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event while receiving 18 months of COBRA continuation

coverage, the spouse or registered domestic partner and dependent children in your family can get up to

18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the

second qualifying event is properly given to the Plan. This extension may be available to the spouse and

any dependent children receiving continuation coverage if the employee or former employee dies, becomes

entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or

terminates a registered domestic partnership, or if the dependent child stops being eligible under the Plan

as a dependent child, but only if the event would have caused the spouse or dependent child to lose

coverage under the Plan had the first qualifying event not occurred.

Initial COBRA Notice-HRM:Benefits: 04/2017

APPENDIX A

Health Care Reimbursement Account (HCRA) Plan continuation coverage

COBRA coverage under the HCRA will be offered only to qualified beneficiaries if there is a positive

balance in the HCRA at the time of the qualifying event. If you elect to continue HCRA participation, you

will make payments on an after-tax basis, and pay an additional 2% administrative fee. You will have

access to your HCRA account balance for the remainder of the year. Note that employees can continue to

submit claims incurred prior to the date that their participation in the HCRA plan ended. Eligibility for

participation in the HCRA plan ceases at the end of the plan year.

If You Have Questions

If you have any questions concerning the information in this notice, your rights to coverage, or if you want

a copy of your summary plan description, you should contact Campus Benefits Office Staff Responsible

for Cobra Administration of The Plan, With Telephone Number and Address.

Keep Your Plan Informed of Address Changes

In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in

the addresses of family members. You should also keep a copy, for your records, of any notices you send

to the Plan Administrator.

Plan Contact Information

Information about the Plan and COBRA coverage can be obtained upon request by contacting CSU at:

Specify Campus, Appropriate Address with Name and Telephone Number of Contact

APPENDIX B

COBRA Continuation Coverage Election Notice

Insert Date

Optional: Name and Address of Qualified Beneficiary

Dear: Name of Qualified Beneficiary(ies) by Name or Status

This notice contains important information about your right to continue your health care coverage in

the enter name of group health plan (the Plan), as well as other health coverage alternatives that may be

available to you through the Health Insurance Marketplace at www.HealthCare.gov. You may be able to

get coverage through the Health Insurance Marketplace that costs less than COBRA continuation

coverage. Please read the information contained in this notice very carefully.

To elect COBRA continuation coverage, follow the instructions on the next page to complete the enclosed

Election Form and submit it to us.

If you do not elect COBRA continuation coverage, your coverage under the Plan will end on Insert Date

Coverage Ends due to [see checked box below]:

End of employment Reduction in hours of employment

Death of employee Divorce or legal separation or Annulment

Entitlement to Medicare Dissolution of Registered Domestic Partnership

Loss of dependent child status

Each person (“qualified beneficiary”) in the category(ies) checked below is entitled to elect COBRA

continuation coverage, which will continue group health care coverage under the Plan for up to enter 18 or

36, as appropriate months for the following qualified beneficiaries specified below:

Employee or former employee [Insert Name]

Spouse or former spouse [Insert Name]

Registered Domestic Partner or Former Registered Domestic Partner [Insert Name]

Dependent child(ren) covered under the Plan on the day before the event that caused the loss of

coverage [Insert Name]

[Insert Name] [Insert Name]

Child who is losing coverage under the Plan because he or she is no longer a dependent under the

Plan [Insert Date]

If elected, COBRA continuation coverage will begin on [Insert Date] and can last until [Insert Date].

You may elect any of the following checked options for COBRA continuation coverage:

CalPERS Health Coverage: [Specify Health Plan] [Insert Amount] Per Month

CSU Dental Coverage: [Specify Health Plan] [Insert Amount] Per Month

CSU Vision Coverage (VSP) [Insert Amount] Per Month

Health Care Reimbursement Account (HCRA) Plan (Monthly COBRA Cost based on 102% of monthly

election amount).

Insurance Exchange COBRA General Notice - HRM: Benefits: 04/2017

APPENDIX B

You do not have to send any payment with the Election Form. Important additional information about payment

for COBRA continuation coverage is included in the pages following the Election Form.

There may be other coverage options for you and your family. In the Health Insurance 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.

If you have any questions about your rights to COBRA continuation coverage, you should contact

ENTER ADDRESS AND PHONE NUMBER(S) FOR CAMPUS BENEFITS OFFICE CONTACT.

Insurance Exchange COBRA General Notice - HRM: Benefits: 04/2017

APPENDIX B

COBRA Continuation Coverage Election Form

I (We) elect COBRA continuation coverage in the Enter the Name of the Plan (the Plan) as indicated

below:

Name

Date of Birth Relationship to Employee SSN (or other identifier)

[Add if appropriate: Coverage option elected: Insert Plan]

Signature Date

Print Name Relationship to individual(s) listed above

Print Address Telephone number

Instructions

To elect COBRA continuation coverage, complete this Election Form and return it to us. Under

federal law, you have 60 days after the date of this notice to decide whether you want to elect COBRA

continuation coverage under the Plan.

Send completed Election Form to: Enter Name and Address of Campus Benefits Office Contact Person

This Election Form must be completed and returned by mail or describe other means of submission and due

date. If mailed, it must be post-marked no later than enter date.

If you do not submit a completed Election Form by the due date shown above, 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. However, if you

change your mind after first rejecting COBRA continuation coverage, your COBRA continuation coverage will

begin on the date you furnish the completed Election Form.

Read the important information about your rights included in the pages after the Election Form.

a. Insert Appropriate Information

b. Insert Appropriate Information

c. Insert Appropriate Information

d. Insert Appropriate Information

Insurance Exchange COBRA General Notice - HRM: Benefits: 04/2017

APPENDIX B

Important Information

About Your COBRA Continuation Coverage Rights

What is continuation coverage?

Federal law requires that most group health plans (including this Plan) give employees and their families the

opportunity to continue their health care coverage when there is a “qualifying event” that would result in a loss

of coverage under an employer’s plan. Depending on the type of qualifying event, “qualified beneficiaries” can

include the employee (or retired employee) covered under the group health plan, the covered employee’s

spouse, and the dependent children of the covered employee. CSU is voluntarily treating current and former

registered domestic partners as qualified beneficiaries for COBRA purposes.

Continuation coverage is the same coverage that the Plan gives to other participants or beneficiaries under

the Plan who are not receiving continuation coverage. 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.

How long will continuation coverage last?

In the case of a loss of coverage due to end of employment or reduction in hours of employment, coverage

generally may be continued for up to a total of 18 months. In the case of losses of coverage due to an

employee’s death, divorce or legal separation, the termination of a registered domestic partnership or the

employee’s becoming entitled to Medicare benefits or a dependent child ceasing to be a dependent under the

terms of the plan, coverage may be continued for up to a total of 36 months. When the qualifying event is the

end of employment or reduction of the employee's hours of employment, and the employee became entitled to

Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified

beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement. This notice

shows the maximum period of continuation coverage available to the qualified beneficiaries.

Continuation coverage will be terminated before the end of the maximum period if:

 any required premium is not paid in full on time,

 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 limitations on plans’ imposing a preexisting 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, or

 the employer ceases to provide any group health plan for its employees.

Continuation coverage may also be terminated for any reason the Plan would terminate coverage of a

participant or beneficiary not receiving continuation coverage (such as fraud).

Insurance Exchange COBRA General Notice - HRM: Benefits: 04/2017

APPENDIX B

[If the maximum period shown on page 1 of this notice is less than 36 months, the following three

paragraphs are applicable to you:]

How can you extend the length of COBRA continuation 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 [Enter Name and

Address of Campus Benefits Office Contact Person] of a disability or a second qualifying event in order to

extend the period of continuation coverage. Failure to provide notice of a disability or second qualifying event

may affect the right to extend the period of continuation coverage.

Social Security Disability Extension to the 18-Month Period

The 18 months of continuation coverage may be extended for an additional 11 months of coverage, up to a

maximum of 29 months if any of the qualified beneficiaries is determined by the Social Security

Administration (SSA) 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.

This extended period allows disabled persons continued coverage for the period of time that it normally takes

to become eligible for Medicare. Premiums for this coverage beyond the initial 18 months will be calculated at

150% of the State's group coverage premium rate and will continue to be paid monthly directly to the plan or

its designee.

It is the qualified beneficiary's responsibility to obtain this disability determination from the Social

Security Administration and provide a copy of the determination to the appropriate plan within 60

days after the date of determination and before the original 18-month COBRA eligibility period expires.

Each qualified beneficiary who has elected continuation coverage will be entitled to the 11-month disability

extension if one of them qualifies. If the qualified beneficiary is determined by SSA to no longer be disabled,

you must notify the Plan of that fact within 30 days after 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 termination of a registered domestic partnership, or 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.

You must notify the Plan within 60 days after a second qualifying event occurs if you want to extend

your continuation coverage.

Special Medicare Entitlement Rule for Dependents Only

If an employee becomes entitled to Medicare benefits prior to the date of an 18-month qualifying event,

then his/her dependents is eligible for 18 months of COBRA continuation coverage, or 36 months

measured from the date of the Medicare entitlement, whichever is greater.

Insurance Exchange COBRA General Notice - HRM: Benefits: 04/2017

APPENDIX B

Example: If an employee becomes entitled to Medicare seven (7) months prior to termination of employment,

then the dependents will be offered 29 months of continuation coverage. The employee is only offered 18

months.

Additional Continuation of Coverage Rights for Certain Qualified Beneficiaries (for California only)

Assembly Bill (AB) 1401 (Cal-COBRA) permits specified individuals who begin continuation coverage on or after

January 1, 2003, and who subsequently exhaust all available Federal COBRA continuation coverage, the

opportunity to extend their coverage term up to 36 months (includes all prior COBRA coverage), regardless of the

nature of the initial COBRA qualifying event. The provisions of AB 1401 apply to health coverage only (not dental

or vision) and became effective on September 1, 2003. Premiums are 110% of the corresponding group rate.

An individual who terminated employment may continue coverage for 18 months under Federal COBRA (at a cost

of 102%), and then may request continued coverage for an additional 18 months (at a cost of 110%) under AB

1401. An individual who meets the Social Security Administration’s definition of disabled (which entitles the

disabled individual to up to 29 months of continuation coverage) is eligible for an additional seven months of

coverage under AB 1401. The coverage cost would be 102% for 18 months of coverage under Federal COBRA,

150% during the disability extension period (months 19 through 29) and 110% for the additional seven months of

coverage under AB 1401.

Participants must apply for the extension directly with the insurance carrier or health plan prior to the expiration of

their Federal COBRA coverage. Participants should be referred to CalPERS or their health plan for additional

information.

How can you elect COBRA continuation coverage?

To elect continuation coverage, you must complete the Election Form and furnish it according to the directions

on the form. 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.

In considering whether to elect continuation coverage, you should take into account that you have special

enrollment rights under federal law. You have the right to request special enrollment in another group health

plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within 30 days

after your group health coverage ends because of the qualifying event listed above. You will also have the

same special enrollment right at the end of continuation coverage if you get continuation coverage for the

maximum time available to you.

Electing COBRA under the HCRA

COBRA coverage under the HCRA will be offered only to qualified beneficiaries if there is a positive balance in

the HCRA at the time of the qualifying event. If you elect to continue HCRA participation, you will make

payments on an after-tax basis, and pay an additional 2% administrative fee. You will have access to your

HCRA account balance for the remainder of the year. Note that employees can continue to submit claims

incurred prior to the date that their participation in the HCRA plan ended. Eligibility for participation in the

HCRA plan ceases at the end of the plan year. If you are interested in this alternative, contact [Insert Benefits

Office Staff Contact Information] for more information.

Insurance Exchange COBRA General Notice - HRM: Benefits: 04/2017

APPENDIX B

How much does COBRA continuation coverage cost?

Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. The

amount a qualified beneficiary may be required to pay may not exceed 102 percent (or, in the case of an

extension 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 or

beneficiary who is not receiving continuation coverage. The required payment for each continuation coverage

period for each option is described in this notice.

When and how must payment for COBRA continuation coverage be made?

First payment for continuation coverage

If you elect continuation coverage, 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. (This is the date the Election Notice is post-marked, if mailed.) If you do not make your first

payment for continuation coverage in full not later than 45 days after the date of your election, you will

lose all continuation coverage rights under the Plan. You are responsible for making sure that the amount of your

first payment is correct. You may contact Enter Name, Address and Telephone Number of Campus Benefits Office

Contact to confirm the correct amount of your first payment.

Periodic payments for continuation coverage

After you make your first payment for continuation coverage, you will be required to make periodic payments for

each subsequent coverage period. The amount due for each coverage period for each qualified beneficiary is

shown in this notice. The periodic payments can be made on a monthly basis. Under the Plan, each of these

periodic payments for continuation coverage is due on the first day of the month for that coverage

period. 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. The Plan [select one:

will or will not] send periodic notices of payments due for these coverage periods.

Grace periods for periodic payments

Although periodic payments are due on the dates shown above, you will be given a grace period of 30

days after the first day of the coverage period to make each periodic payment. 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. However, if you pay a periodic payment later than the first day of the

coverage period to which it applies, but before the end of the grace period for the coverage period, your coverage

under the Plan will be suspended as of the first day of the coverage period and then retroactively reinstated

(going back to the first day of the coverage period) when the periodic payment is received. This means that any

claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted

once your coverage is reinstated.

If you fail to make a periodic payment before the end of the grace period for that coverage period, you

will lose all rights to continuation coverage under the Plan.

Your first payment and all periodic payments for continuation coverage should be sent to: [See Payment

Addresses Below:]

Insurance Exchange COBRA General Notice - HRM: Benefits: 04/2017

APPENDIX B

Health

Payment address information will be provided by the

Health Plan

Dental

For Delta Dental (PPO) and DeltaCare USA

(DHMO) Plans:

Wolfpack Insurance Services, Inc.

P.O. Box 833

Belmont, California 94002

Telephone: (800) 296-0192

Fax: (650) 591-4022

Vision

VSP/COBRA ADMINISTRATION

P.O. Box 997100

Sacramento, California 95899-7100

Telephone: (800) 400-4569

Fax: 916-463-9031

HCRA

ASI P. O. Box 6044

Columbia, MO 65205-6044

Attention: COBRA Telephone:

(800) 659-3035

Fax: 877-879-9038

Insurance Exchange COBRA General Notice - HRM: Benefits: 04/2017

APPENDIX B

For more information

This notice does not fully describe continuation coverage or other rights under the Plan. More information

about continuation coverage and your rights under the Plan is available in your summary plan description or

from the Plan Administrator.

If you have any questions concerning the information in this notice, your rights to coverage, or if you want a

copy of your summary plan description, you should contact Campus Benefits Office Staff Responsible For

Cobra Administration For The Plan, With Telephone Number And Address.

For more information about health insurance options available through a Health Insurance Marketplace, visit

www.healthcare.gov.

For Persons Eligible for Medi-Cal

The Health Insurance Premium Payment (HIPP) Program may pay COBRA premiums in certain cases for

persons eligible for Medi-Cal. You may e-mail your questions to the Department of Health Care Services at:

www.HIPP@dhs.ca.gov.

For Persons Disabled by HIV/AIDS

Under the Comprehensive AIDS Resources Emergency (CARE) Act of 1990, the Health Insurance Premium

Payment (HIPP) Program may pay COBRA premiums for persons unable to work because of a disability due to

HIV/AIDS. You may e-mail your questions to the Department of Health Care Services at:

www.HIPP@dhs.ca.gov.

Keep Your Plan Informed of Address Changes

In order to protect your and your family’s rights, you should keep the Plan Administrator informed 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 the Plan Administrator.

APPENDIX C

NOTICE OF INELIGIBILITY FOR COBRA (sample)

[If CSU receives notice from a qualified beneficiary of a qualifying event, a second qualfiying event, or a

determination of disability by the Social Security Administration (SSA) and CSU determines that the individual is not

entitled to COBRA continuation coverage, CSU must provide the individual with a notice. The notice must be written

in a manner that is understandable to the average plan participant and must explain why the individual is not entitled

to COBRA. The notice must be provided within 14 days after CSU’s receipt of the notice of a qualifying event, a

second qualifying event or a determination of disability by the SSA. This sample notice may be used to satisfy this

obligation. Delete this explanation before reproducing the sample form.]

[Insert name of plan]

California State University [Insert name of campus]

[Insert date]

To: [Insert name of ineligible party]

You are receiving this notice because you recently made a request for COBRA continuation coverage

under the [insert name of plan]. However, the California State University (CSU) has determined that you

are not eligible for COBRA continuation coverage for the following reason(s):

[Insert explanation of why individual is ineligible]

Please contact [insert name of individual responsible for COBRA administration, with telephone

number and address] if you have any questions about this notice or COBRA continuation coverage.

PERS USE ONLY DOCUMENT REFERENCE NUMBER

GROUP CONTINUATION

COVERAGE

CONSOLIDATED OMNIBUS BUDGET

RECONCILIATION ACT "COBRA"

PERS-HBD-85 (Rev 6/13)

Public Employees' Retirement System

Health Account Services

P.O. Box 942715

Sacramento, CA 94229-2715

888 CalPERS (or 888-225-7377)

TTY (877) 249-7442 Fax (800) 959-6545

INSTRUCTIONS FOR COMPLETING THIS FORM ARE ON THE REVERSE SIDE. PLEASE TYPE

PART A: ORIGINAL QUALIFYING EVENT AND DATES

1. Type of

Action

NEW

CHANGE

2. QUALIFYING EVENT

EMPLOYMENT SEPARATION TIME BASE REDUCTION

DIVORCE/LEGAL SEPARATION

CHILD CEASES TO BE A DEPENDENT

DEALTH OF AN EMPLOYEE/RETIREE

DEPENDENT CONTINUATION-ORIGINAL ENROLLEE ELIGIBLE FOR MEDICARE

4. COBRA ENROLLMENT PERIOD

FROM 01

PART B: ENROLLEE INFORMATION

5. COBRA ENROLLEE (MAY BE DIFFERENT THAN SUBSCRIBER)

SOCIAL SECURITY NUMBER

6. SUBSCRIBER (EMPLOYEE/RETIREE)

NAME

ADDRESS

CITY, STATE, ZIP

NAME

DAY PHONE

( )

MARRIED

BIRTHDATE

SEX

PART D: DEPENDENT INFORMATION

PART C: CARRIER INFORMATION

7. NAME AND ADDRESS OF HEALTH PLAN

PLAN CODE: ________________

PREMIUM: $ ________________

PHONE:

PART E: ENROLLMENT CHANGES

9. NAME OF PRIOR HEALTH PLAN

LIST OF ALL PERSONS (including self)

TO BE ENROLLED:

DATE OF BIRTH FAMILY

RELATIONSHIP

SELF

(FIRST) (MI) (LAST)

SSN

(FIRST) (MI) (LAST)

SSN

(FIRST) (MI) (LAST)

SSN

(FIRST) (MI) (LAST)

SSN

MO.

DAY

_____________________________________________

10. PRIOR PLAN CODE

13. EFFECTIVE DATE OF

CHANGE

12. PERMITTING EVENT

DATE

11. PERMITTING

EVENT CODE

PART G: AGENCY INFORMATION

15. AGENCY NAME ______________________________________

PART F: SIGNATURE OF ENROLLEE

14. I AGREE TO PAY THE PREMIUM FOR THE COVERAGE DIRECTLY TO THE CARRIER LISTED ABOVE. I UNDERSTAND THAT

I AM REQUIRED TO SEND THE INITIAL PAYMENT PRIOR TO EFFECTIVE DATE OF ENROLLMENT AND AGREE TO MAKE

FUTURE PAYMENTS IN A TIMELY MANNER AS REQUIRED BY THE CARRIER. I UNERSTAND THAT FAILURE TO PAY THE

PREMIUM WILL RESULT IN AUTOMATIC TERMINATION OF COVERAGE. I CERTIFY THAT THE INFORMATION PROVIDED BY

ME IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND ABILITY.

AGENCY CODE ______________ UNIT CODE _________

3. EVENT DATE

____ ____

____________________________________________________________________

_____________________________________

SIGNATURE OF COBRA ENROLLEE (SEE ATTACHMENT FOR PRIVACY INFORMATION)

DATE SIGNED

16. HEALTH BENEFITS OFFICER'S SIGNATURE

DATE RECEIVED ___________

PHONE ______________

YES NO

MALE

FEMALE

www.calpers.ca.gov

APPENDIX D

PRIVACY INFORMATION

IMPORTANT: It is the responsibility of the COBRA enrollee to report enrollment changes in a timely

manner. Enrollment change requests must be submitted in accordance with existing regulations,

laws, and the time limits applicable to the Public Employees' Medical and Hospital Care Act. All

change requests are directed through the agency listed in Part G.

Part D: 8. List all family members to be enrolled, including self.

Action Code: Use "A" to indicate which person is being added (or newly enrolled). Use "D" to

indicate if an individual is being deleted from an existing COBRA enrollment. An Action Code is

not required when changing carriers.

IMPORTANT: The addition or deletion of family members is regulated by time limits which are

identical to those for active enrollees (subscribers).

Part E: 9-10 Name and Plan Code of prior health plan if COBRA coverage is being changed.

10-13 to be completed by the Health Benefits Officer

Part F: 14. Signature of COBRA enrollee and date signed.

Part G: 15-16: To be completed by the (former) employing agency. For (former) dependents of

retirees, CalPERS is the "employing agency".

Submission of the requested information is mandatory. The information is collected pursuant to the Government

Code Sections (20000 et. seq) and will be used for administration of the Board's duties under the California Public

Employees' Retirement Law, the Social Security Act, and the Public Employees' Medical and Hospital Care Act, as

the case may be. Portions of this information may be transferred to another government agency (such as your

employer) but only in strict accordance with current statutes regarding confidentiality. Failure to supply the

information may result in the System being unable to perform its functions regarding your status.

You have the right to review your membership files maintained by the System. For questions concerning your rights

under the Information Practices Act of 1977, please contact the Information Practices Act Coordinator, CalPERS,

P.O. Box 942702, Sacramento, CA 94229-2702.

Part B: 5. Please provide all requested information.

6. If the COBRA enrollee is a former dependent, the employee/retiree must be identified in box 6.

Part C: 7. Please identify the carrier. The COBRA enrollee must continue the same coverage which he or

she had as an employee or as a dependent. Carrier changes are only allowed during the Open

Enrollment period or if the enrollee moves into or out of a carrier's geographic service area. The

carrier's name, address, and phone number can be found in the annual Health Benefit Summary

which is available in all employing agencies. The monthly premium may not exceed 102% of the

group rate.

INSTRUCTIONS FOR THE COMPLETION OF THE FORM HBD-85 (08/2011)

Part A 1. Type of Action check " NEW " if this is a new enrollment.

Check " CHANGE " if family member is added, deleted, or any plan changes.

2. Check applicable Original Qualifying Event and Dates.

3. Provide original event date (separation, date of divorce, etc.).

4. Original COBRA enrollment period.

Examples:

Separation from enrollment 4-15-2010 (Perm. Event) FROM 6-1-2010 TO 11-30-2011

Child attains age 26 on 6-15-2010 (Perm. Event) FROM 7-1-2010 TO 6-30-2013

APPENDIX D

Privacy Notice

The privacy of personal information is of the utmost importance to CalPERS.

The following information is provided to you in compliance with the Information

Practices Act of 1977 and the Federal Privacy Act of 1974.

Information Purpose

The information requested is collected pursuant

to the Government Code (sections

20000 et seq.)

and will be used for administration of Board

duties under the Retirement Law, the Social

Security Act, and the Public Employees’ Medical

and Hospital Care Act, as the case may be.

Submission of the requested information is

mandatory. Failure to comply may result in

CalPERS being unable to perform its functions

regarding your status.

Please do not include information that is

not requested.

Social Security Numbers

Social Security numbers are collected on a

mandatory and voluntary basis. If this is CalPERS’

ﬁrst request for disclosure of your Social Security

number, then disclosure is mandatory. If your

Social Security number has already been provided,

disclosure is voluntary. Due to the use of Social

Security numbers by other agencies for

identiﬁcation purposes, we may be unable to

verify eligibility for beneﬁts without the number.

Social Security numbers are used for the

following purposes:

1. Enrollee identiﬁcation

2. Payroll deduction/state contributions

3. Billing of contracting agencies for employee/

employer contributions

4. Reports to CalPERS and other state agencies

5. Coordination of beneﬁts among carriers

6. Resolving member appeals, complaints,

or grievances with health plan carriers

Information Disclosure

Portions of this information may be transferred

to other state agencies (such as your employer),

physicians, and insurance carriers, but only

in strict accordance with current statutes

regarding conﬁdentiality.

Your Rights

You have the right to review your membership

ﬁles maintained by the System. For questions

about this notice, our Privacy Policy, or your rights,

please write to the CalPERS Privacy Ocer at

400 Q Street, Sacramento, CA 95811 or call us

at 888 CalPERS (or 888-225-7377).

May 2016

APPENDIX D

Health Account Services

P.O. Box 942715

Sacrame

CA 94229-2715

888 CalPERS (or 888-225-7377) Fax (800) 959-6545

TTY (877) 249-7442

HBD-85R (Rev 6/13)

SUBJECT: CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT

(

COBRA

)

General Information –

Election

Thi

s form is to be used by Retirees

onl

For active members, please use the HBD-85

form.

The Federal COBRA legislation allows the continuation of health and dental coverage to family

members who lost their eligibility for coverage as dependents on or after August 1,

1986,

for one

the following

reasons:

a. Divorce or legal separation

b. Attainment of age 26

(child)

c. Death of e

mployee/annuitant (if enrolled family member is not eligible for

monthly

survivor/beneficiary allowance from

CalPERS)

The coverage can be continued for up to 36 months, but the premium payment

(102%

of the

group

rate) is the responsibility of the enrollee. No state contribution is available to pay for the COBRA

coverage. To enroll under

COBRA

please fill out the information

below:

Name and Social Security Number of (former) prime life

enrollee:

_________________________________________________ SSN: _______ - ________ - ________

Name and Social Security Number of COBRA enrollee, if different from

above:

Name: ___________________________________________________

SSN

: _____ - _____ - ______

Addres

_______________________________________________________________________________

Daytim

Phone

No:

( )

______________________________________________________________

QUALIFYING EVENTS: Length of coverage is 36

months.

Divo

rce or legal se

paration

Child attained age

Death of employee/annuitant

Date of the above qualifying event: ______________________________________________________

ELECTION TO ENROLL IN OR DECLINE COBRA CONTINUATION COVERAGE:

Health

Benefits

Enroll

Decline

Dental

Coverage

Enroll Decline

Signature of COBRA

Enrollee

____________________________________ Date: _____________

(mm/dd/yyyy)

Please

return this election within 60 days after receipt to the address indicated

above

CalPERS will

prepare

actual enrollment document and send a copy to the COBRA enrollee and to the

carrie

A premium

payable to the carrier may be enclosed, or the carrier will bill the

enrollee

directly. The effective date for COBRA

coverage

the same as the date on which coverage as a dependent is

terminat

ed.

CalPERS

Public Employees’ Retirement System

Health Account Services

P.O. Box 942715

Sacramento, CA 94229-2715

www.calpers.ca.gov

APPENDIX D

Privacy Notice

The privacy of personal information is of the utmost importance to CalPERS.

The following information is provided to you in compliance with the Information

Practices Act of 1977 and the Federal Privacy Act of 1974.

Information Purpose

The information requested is collected pursuant

to the Government Code (sections

20000 et seq.)

and will be used for administration of Board

duties under the Retirement Law, the Social

Security Act, and the Public Employees’ Medical

and Hospital Care Act, as the case may be.

Submission of the requested information is

mandatory. Failure to comply may result in

CalPERS being unable to perform its functions

regarding your status.

Please do not include information that is

not requested.

Social Security Numbers

Social Security numbers are collected on a

mandatory and voluntary basis. If this is CalPERS’

ﬁrst request for disclosure of your Social Security

number, then disclosure is mandatory. If your

Social Security number has already been provided,

disclosure is voluntary. Due to the use of Social

Security numbers by other agencies for

identiﬁcation purposes, we may be unable to

verify eligibility for beneﬁts without the number.

Social Security numbers are used for the

following purposes:

1. Enrollee identiﬁcation

2. Payroll deduction/state contributions

3. Billing of contracting agencies for employee/

employer contributions

4. Reports to CalPERS and other state agencies

5. Coordination of beneﬁts among carriers

6. Resolving member appeals, complaints,

or grievances with health plan carriers

Information Disclosure

Portions of this information may be transferred

to other state agencies (such as your employer),

physicians, and insurance carriers, but only

in strict accordance with current statutes

regarding conﬁdentiality.

Your Rights

You have the right to review your membership

ﬁles maintained by the System. For questions

about this notice, our Privacy Policy, or your rights,

please write to the CalPERS Privacy Ocer at

400 Q Street, Sacramento, CA 95811 or call us

at 888 CalPERS (or 888-225-7377).

May 2016

APPENDIX D

COBRA ENROLLMENT CHANGE FORM

- CSU

Delta Dental of California

 Delta Dental PPO

 DeltaCare

USA

Change Dental Plans*

Current Enrollment

Terminate Enrollee Coverage

Change Dental Plans*

Cancel COBRA enrollment



Group No.

SSN/Enrollee ID Number Correction or

previous ID under which benefits are received

Division State

Social Security Number Enrollee ID Number (if applicable) Gender



Male

 Female  Single  Married Reg. Domestic Partner

First Name Last Name Middle Initial

Mailing Address (Street) City State Zip Code

E-mail Address (internal use only) Phone Number

( ) -

Work  Home 

Network Facility Name (DeltaCare USA only) Network Facility Number (DeltaCare USA only)

Name of Other Dental Carrier

(if applicable)

Policy Holder Name (first/last)

Policy Holder Street Address City State

Zip Code

Dependent Information

Relationship

Dependent First Name

(last name only if different from enrollee)

Date New Dependent

Acquired

Add / Term Social Security Number Date of Birth Male / Female Disabled***

Network Facility Number

‡

(DeltaCare USA only)

Spouse/Reg. Domestic Partner

 

/ /

 



Dependent

 

/ /

  

Dependent

 

/ /

 



Date

/ /

Please mail form to Wolfpack, P.O. Box 833, Belmont, CA 94002

Form 3460 CA - CSU

(03/27/17)



New Enrollment

Add/Delete Dependent

Marital Status Change

Address Change

Enrollees can change plans only during open enrollment or due to a qualifying status change unless allowed by the group contract.

Primary Enrollee Information



Date of Birth

Marital Status



Phone Type

Cell



Date of Birth

Effective Date

of Other Policy

Signature of Enrollee

DeltaCare USA is our prepaid plan that features set copayments, no annual deductibles and no maximums for covered benefits. Enrollees must select a primary care dentist in the DeltaCare USA network from whom they receive

treatment and must reside in California.

deltadentalins.com/csu

Select a Plan:

Delta Dental PPO

DeltaCare USA

(Check only one)



I authorize the above changes to my existing COBRA enrollment. I certify that the above information is true and correct to the best of my knowledge. I understand that changes can only be made if

I experience a qualifying family status change, in which case the change must be consistent with that event or during open enrollment.

Dependent

 

  

Please attach a separate sheet for additional dependent information. All dependents listed will be considered enrolled. ***Additional documentation will be required for disabled status.

‡

Maximum of three facilities per family.



VERY IMPORTANT - Please Print Legibly

Enrollee/Change Information

COBRA Effective Date_____________

Name of Employer: CSU

Campus Contact Name_______________________

Phone Number______________________________

APPENDIX D

ELECTION OF CONTINUED VISION COVERAGE THROUGH COBRA

Questions? Call 800.400.4569 opt 2

CSUCOBRA2015_revised11/2014 GS-1101

Group Name:

CALIFORNIA STATE UNIVERSITY #30059426

Date of Qualifying Event: Date COBRA Coverage Begins:

ELECTING CONTINUATION OF VISION CARE COVERAGE:

Under COBRA, federal regulations specify that you and/or your dependent(s) have 60 days (the “Election Period”) from the later

of the date of continuation of coverage/COBRA notice, or the date of the loss of coverage to elect to continue participation, and 45

days from the date of election to submit the first payment to VSP.

DESCRIPTION OF QUALIFYING EVENT:

 Disabled on the date of qualifying event

 Legal separation or divorce

 Dissolution of Registered Domestic Partnership

 Loss of child’s dependent status

 Reduction of hours

 Retiree

 Surviving Dependents / Widow

 Former Employee

ELIGIBILITY PERIOD:

 18-month coverage

 29-month coverage

 36-month coverage

COBRA APPLICANT INFORMATION:

Name of COBRA Applicant (Last, First, Middle Initial) Social Security Number Birth Date (Month/Day/Year)

Mailing Address (Number, Street, City, State, ZIP)

CURRENT/FORMER EMPLOYEE INFORMATION:

Name of Employee Social Security Number of Employee Relationship to Applicant

ELIGIBLE FAMILY MEMBERS (List dependents to be enrolled. Attach separate listing if more dependents exist.):

Name (Last, First, Middle Initial): Social Security Number: Birth Date (Month/Day/Year): Relationship to Employee:

MONTHLY CONTRIBUTION AMOUNT:

I elect to continue vision coverage at a rate of $8.03 per month. Rates and benefits are subject to change based upon the group’s

contract.

PAYMENT REQUIREMENTS:

All payments must be made directly to VSP. You will receive a coupon booklet for payments, which confirms your continued

participation. The first payment submitted to VSP must be sufficient to bring payments current. Payments are due to VSP by the

1st of the month. There is a 30-day grace period. If VSP does not receive payment by the 30th of each month, your participation

will end on the last day of the preceding month.

NOTIFICATION AGREEMENT and SIGNATURES (Parent or Legal Guardian must sign if dependents are minor children):

By signing below, I understand that should I become eligible under another group plan or Medicare, after electing COBRA

continuation coverage, I will notify VSP in writing to terminate my vision care coverage.

Signature of COBRA Applicant:

Daytime Telephone Number

( )

Date:

Signature of Benefits Representative:

Campus: Date:

RETURN COMPLETED FORM TO:

VSP/COBRA ADMINISTRATOR

PO BOX 997100

SACRAMENTO, CA 95899-7100

APPENDIX D

ELECTION OF CONTINUED VISION COVERAGE THROUGH COBRA

Questions? Call 1.800.400.4569

CSUCOBRA2015

Group Name:

CALIFORNIA STATE UNIVERSITY (CSU)

RETIREE VOLUNTARY VISION PLAN

Date of Qualifying Event: Date COBRA Coverage Begins:

ELECTING CONTINUATION OF VISION CARE COVERAGE:

Under COBRA, federal regulations specify that you and/or your dependent(s) have 60 days (the “Election Period”) from the later

of the date of continuation of coverage/COBRA notice, or the date of the loss of coverage to elect to continue participation, and 45

days from the date of election to submit the first payment to VSP.

DESCRIPTION OF QUALIFYING EVENT:

 Legal separation or divorce

 Dissolution of Registered Domestic Partnership

 Surviving Dependents / Widow

 Loss of child’s dependent status

ELIGIBILITY PERIOD:

 36-month coverage

COBRA APPLICANT INFORMATION:

Name of COBRA Applicant (Last, First, Middle Initial) Social Security Number Birth Date (Month/Day/Year)

Mailing Address (Number, Street, City, State, ZIP)

CURRENT/FORMER EMPLOYEE INFORMATION:

Name of Employee Social Security Number of Employee Relationship to Applicant

ELIGIBLE FAMILY MEMBERS (List dependents to be enrolled. Attach separate listing if more dependents exist.):

Name (Last, First, Middle Initial): Social Security Number: Birth Date (Month/Day/Year): Gender: Relationship to Employee:

MONTHLY CONTRIBUTION AMOUNT:

 One Party: $5.65  Two Party: $10.50  Three Party: $11.26

I elect to continue vision coverage at a rate of $___.___ per month. Rates and benefits are subject to change based upon the

group’s contract.

PAYMENT REQUIREMENTS:

All payments must be made directly to VSP. You will receive a coupon booklet for payments, which confirms your continued

participation. The first payment submitted to VSP must be sufficient to bring payments current. Payments are due to VSP by the

1st of the month. There is a 30-day grace period. If VSP does not receive payment by the 30th of each month, your participation

will end on the last day of the preceding month.

NOTIFICATION AGREEMENT and SIGNATURES (Parent or Legal Guardian must sign if dependents are minor children):

By signing below, I understand that should I become eligible under another group plan or Medicare, after electing COBRA

continuation coverage, I will notify VSP in writing to terminate my vision care coverage.

Signature of COBRA Applicant:

Daytime Telephone Number

( )

Date:

Signature of Benefits Representative:

Campus: Date:

RETURN COMPLETED FORM TO:

VSP/COBRA ADMINISTRATOR - P.O. BOX 997100

SACRAMENTO, CA 95899-7100

APPENDIX D

Health Care Reimbursement Account (HCRA)

REQUEST FOR DIRECT PAY ENROLLMENT (COBRA AND LEAVE WITHOUT PAY)

Complete this form and return to the Campus Benefits Representative

Employee Name (First) (MI) (Last)

Social Security Number

Campus

Address

City

State

Zip

Signature



Date

Reason for Request (check one)

Monthly

Contribution

Amount

$_______

Separation from Employment

Termination Date ______________

Leave Without Pay

Effective Date ______________

Expected Length ____________

Is this a FMLA leave? Yes No

Complete this section if applicant is not the employee

Name of Applicant

Relationship to Employee

Social Security Number

Signature



Date

Please note the following information:

1. Continuation payments are not made via the payroll system; therefore, there is no income tax savings associated

with continuation of the HCRA Plan.

2. You must have a balance in your account prior to separation or leave without pay to be eligible for continued

participation.

3. If request for continued participation is approved, you may participate until the end of the plan year. If you go on

leave without pay and it extends beyond the end of the plan year, you will not be eligible to reenroll in the plan until

you return to active status. Separated employees are not eligible to reenroll in subsequent years.

4. Participation after termination or other COBRA qualifying events will be pursuant to COBRA qualification. Under

COBRA, federal regulations specify that you and/or your dependent(s) have 60 days (the “Election Period”) from

the later of the date of continuation of coverage/COBRA notice, or the date of the loss of coverage to elect to

continue participation, and 45 days from the date of election to submit the first contribution to ASI, the Third Party

Administrator. Eligibility based on a leave of absence will be in accordance with the same timelines.

5. You will receive a coupon booklet for payments, which confirms your continued participation. The first payment

submitted to ASI must be sufficient to bring the payments current.

6. You will be billed 102% of your monthly contribution for COBRA.

7. All payments must be made directly to ASIFlex. Payments are due to ASI the 1

of the month. There is a 30-day

grace period. If ASI does not receive payments by the 30

of each month, your participation will end on the last

day of the preceding month.

Campus Benefits Representative to mail this form to:

ASIFlex

P. O. Box 6044 - COLUMBIA, MO 65205-6044

Telephone Number: (800) 659-3035

CSU Use Only

Account Balance

(at time of Separation or Leave)

Actual Monthly Contribution (including 2% fee)

Action

Approved

Not approved

Signature of Reviewer



Title



Date

November 2014

APPENDIX D

APPENDIX E

CalPERS Health Plans

Plan Code

Plan Name

2017 Monthly COBRA Premiums

One Person

Two People

Three or More

181

Anthem Blue Cross Select HMO

$755.03

$1,510.07

$1,963.09

180

Anthem Blue Cross Traditional HMO

$890.37

$1,780.74

$2,314.96

172

Anthem Blue Cross EPO (Restricted to

Del Norte County)

$755.70

$1,511.40

$1,964.82

127

Anthem Blue Cross EPO (Restricted to

Monterey County)

$755.70

$1,511.40

$1,964.82

141

Blue Shield Access+

$847.05

$1,694.10

$2,202.32

191

Blue Shield Access+ EPO (Restricted to

Colusa, Mendocino & Sierra Counties)

$847.05

$1,694.10

$2,202.32

184

Health Net Salud y Mas

$484.97

$969.94

$1,260.92

185

Health Net SmartCare

$706.75

$1,413.50

$1,837.54

056

Kaiser (CA)

$676.18

$1,352.36

$1,758.06

varies

Kaiser Out-of-State

$959.48

$1,918.97

$2,494.65

222

PERS Choice

$755.70

$1,511.40

$1,964.82

045

PERS Select

$686.72

$1,373.43

$1,785.46

278

PERSCare

$842.90

$1,685.79

$2,191.53

207

PORAC

$712.98

$1,496.34

$1,913.52

189

Sharp (Restricted to San Diego County)

$628.82

$1,257.64

$1,634.93

187

UnitedHealthcare

$699.89

$1,399.79

$1,819.72

CSU Dental Plans

Delta Dental PPO - Indemnity Plan

Dental Plan

Group

Number

Eligible Group

Enrollment

2017

Monthly

COBRA

Premiums

Delta Basic

4918-2091

Public Safety (Unit 8)

Excluded (E99)

CalPERS Annuitants

CalSTRS Annuitants

One Person

Two People

Three or More

$33.47

$63.22

$126.94

Delta

Enhanced

Level I

4918-3091

Teaching Associates (Unit 11)

English Language Program Instructors (Unit 13)

One Person

Two People

Three or More

$40.71

$77.03

$158.80

Delta

Enhanced

Level II

4918-4091

Executive (M98)

Management Personnel Plan (M80)

Confidential (C99)

Physicians (Unit 1)

CSUEU (Units 2, 5, 7, 9)

Faculty (Unit 3)

Academic Support (Unit 4)

Skilled Crafts (Unit 6)

CMA Operating Engineers (Unit 10)

FERP Annuitants

One Person

Two People

Three or More

$50.40

$95.09

$185.78

APPENDIX E

DeltaCare USA

Dental

Plan

Group

Number

Eligible Group

Enrollment

2017

Monthly

COBRA

Premiums

DeltaCare

USA Basic

02034-0011

Public Safety (Unit 8)

Excluded (E99)

Teaching Associates (Unit 11)

English Language Program Instructors (Unit 13)

CalPERS Annuitants

CalSTRS Annuitants

One Person

Two People

Three or More

$20.24

$33.37

$49.36

DeltaCare

USA

Enhanced

02034-0012

Executive (M98)

Management Personnel Plan (M80)

Confidential (C99)

Physicians (Unit 1)

CSUEU (Units 2, 5, 7, 9)

Faculty (Unit 3)

Academic Support (Unit 4)

Skilled Crafts (Unit 6)

CMA Operating Engineers (Unit 10)

FERP Annuitants

One Person

Two People

Three or More

$26.89

$44.37

$65.63

CSU Vision Plan – Actives (Group # 30059426)

The 2017 monthly premium for COBRA vision coverage through VSP is: $8.03

CSU Voluntary Vision Plan – Retirees (Group # 30059425)

The monthly COBRA premiums for the Retiree Voluntary Vision Plan are listed below:

Enrollment

2017 COBRA

Monthly Premium

One Person

Two People

Three or More

$5.65

$10.50

$11.26

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