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Consolidated Omnibus Budget Reconciliation Act (COBRA)

This Section provides information regarding continuation of group coverage for state's dental and vision insurance plans. For enrollment processing information for the state's medical plans, departments should contact CalPERS. For enrollment processing information for the state's FlexElect Program Medical Reimbursement Account refer to the BAM Section 700.

Content

Attachments

401. General Information

 
The Consolidated Omnibus Budget Reconciliation Act (COBRA) is a federal law. The COBRA statute requires that employers with 20 or more employees and maintain group health plans (includes medical, dental, and vision coverage) offer continuation of benefit coverage to covered employees, spouses, *domestic partners (*State of California Legislation, not federal law), and dependent children who lose group plan coverage due to a qualifying event. Plan coverage can be continued for a maximum of 18 or 36 months depending on the qualifying event. Premiums are calculated at 102% of the total group rate and paid by the enrollee on a monthly basis to the plan.
 
What is normally referred to as "COBRA coverage," technically is, "continuation of group coverage."
Departments are responsible for ensuring that covered employees and their eligible dependents are provided with COBRA information, required notices, and assistance in completing enrollment forms. The following standard operating procedures provide information to assist in accomplishing that task. Departments should develop internal procedures on how they perform the COBRA function. The Internal Revenue Service (IRS) and Department of Labor (DOL) set COBRA terms and timeframes.
 
Departments must be aware that under the Americans with Disabilities Act (ADA) there is a requirement to make reasonable accommodations for disabled employees. Reasonable accommodation includes "appropriate assistance to interpret" notices, forms, and materials if requested (including covered non-employees).
 
This manual provides COBRA program information and instructions on three required COBRA notices: Initial General COBRA Notice | Initial General COBRA Notice - Text Only (RTF), COBRA Continuation Election Notice | COBRA Continuation Election Notice - Text Only (RTF), and Notice of Unavailability of Continuation Coverage. You can access these notices as fill and print documents and access general COBRA information available which includes frequently asked questions on the CalHR web site.

  

Good Faith Compliance Standard

All departments should operate its COBRA function in "good faith compliance" with a reasonable interpretation of the statutory standards. To support the evidence of good faith compliance, departments should develop standard operating procedures, provide timely notices, keep copies of notices and election forms, train staff, and audit program.

 

Authority

Federal Legislation (Public Law 99-272, Title X) Consolidated Omnibus Budget Reconciliation Act of 1985 (enacted July 1, 1986)

 

402. Qualified Beneficiary

The term "qualified beneficiary" means, an individual that is eligible to continue group coverage because of a qualifying event. Except for the exception listed below on newborns and adopted children, the individual must be covered under the plan at the time of the qualifying event. If the individual is not covered, he/she is not eligible for COBRA continuation coverage.
 

Eligible Individuals

  • Current employees
  • Former employees
  • Retired employees
  • Spouses*
  • Dependent children**
  • Newborn or child placed for adoption (deemed a qualified beneficiary, although not covered at time of the qualifying event)

Ineligible Individuals

  • Non-resident aliens (with no U.S. income)
  • Individuals (not qualified beneficiaries) under the plan because of another qualified beneficiary's election
* Domestic partners (eligible based on State of California legislation, not federal COBRA law).
 
** National Medical Support Notice (NMSN) and Qualified Medical Child Support Order (QMCSO)
 
Employers are required to provide group health coverage (includes medical, dental, and vision coverage) to children of employees when ordered to do so by state authorities. To ensure that coverage is provided, state, local courts, and agencies can issue medical child support orders.
 
The Personnel Office may see two types of medical support orders: state domestic relations court and agency orders, referred to as "Qualified Medical Child Support Order" (QMCSO), and orders issued by child support enforcement agencies on standardized forms called "National Medical Support Notice" (NMSN). A child enrolled in group coverage when ordered by a NMSN or QMCSO is deemed a qualified beneficiary under COBRA law, regardless of his/her status as a dependent of the covered employee.
 
The Personnel Office should send an Initial General Notice to the custodial parent or guardian ("in care of the child") or agency that sent the NMSN or QMCSO (as a substitute, if child's address is unknown).
 

403. Initial General COBRA Notice

The Initial General COBRA Notice is the first of three required COBRA notices. Refer to Attachment A - Sample Initial General COBRA Notice | Attachment A - Sample Initial General COBRA Notice - Text Only (RTF). The COBRA statute Requires that continuation coverage be offered to covered employees and dependents to continue group coverage in the event coverage is lost due to a qualifying event. The initial notice is intended to provide a summary of their rights, options, and notification responsibilities under COBRA. This is not the COBRA Election Notice.
 
The Initial General COBRA Notice contains the following information:
  • Summary of continuation benefits/description of COBRA terms
  • Listing of qualifying events
  • Outline of employee/dependent notification responsibilities

90-Day Notice Period

The initial notice must be provided to covered individuals "within 90 days after coverage begins". An exception to the 90-day rule is when a qualifying event occurs before the initial notice is provided, and then an initial notice must be provided along with the election notice and election form.

The Personnel Office is required to provide an initial notice to the covered employee, spouse, domestic partner, and covered dependent children (if any), of their rights under COBRA. Departments should customize the notice, depending on whether the employee is single, married, in a domestic partnership, or have dependent children. You may also customize the notice to identify more than one benefit to which there is an enrollment in coverage (e.g., medical, dental, and vision).

The importance of the initial notice cannot be understated. If covered individuals lose group coverage in the future and later claim that they were not aware of their COBRA rights and notification responsibilities, then the Personnel Office will be able to prove that covered individuals were sent an initial notice. This notice provided information on their COBRA rights and notification responsibilities.

Single Notice Rule

A single notice sent first class mail to the last known address, is considered good faith compliance. The notice must be addressed to the employee, spouse and domestic partner. Notification to the covered spouse or domestic partner is generally deemed notification to the covered dependent children who reside at the same address (including any dependent children covered in the future). Please note that to provide reasonable notice on who is included on benefit enrollment, note the enrolled dependents by name on the initial general notice, A separate notice is required when the Personnel Office is aware that covered individuals reside at a different address. Keep a copy in file of the actual notice sent.

Open Enrollment

If covered active employees add a spouse, domestic partner, and/or dependent children to their coverage (e.g., marriage, domestic partnership, loss of coverage, open enrollment period), then an initial notice must be provided to the newly covered spouse or domestic partner.

Changing to Another Plan

If an employee, spouse, domestic partner, or covered dependent children (if any), is covered under one employer group plan and changes from that plan to another plan of the employer, then a new initial notice must be provided (e.g., change from Delta Dental plan to a prepaid plan and/or prepaid plan to a Delta Dental plan).

Court Orders

If a Personnel Office receives a court order that requires enrollment of a child or spouse to an employee's group coverage, then an initial notice must be sent.

Dependent Child: Send initial notice to the custodial parent or guardian ("in care of the child") or agency that sent the court order (as a substitute, if child's address is unknown).

 Spouse: Send initial notice to the spouse or agency ("in care of the spouse") that sent the court order (as a substitute, if spouse's address is unknown). A court order that requires enrollment in group coverage for an ex-spouse is the responsibility of the employee, not the employer. The state does not allow enrollment of an ex-spouse on employees' group coverage.

Approved Notice Delivery Methods

The COBRA statute disclosure regulations require that notices must be furnished using "measures reasonably calculated to ensure actual receipt of the material". The following are examples of acceptable distribution methods (first-class, second- or third class mail, hand-delivery, and electronic disclosure).

Mail Delivery

  • First Class Mail: First class mail is the evidentiary requirement. Proof of receipt is not required. A notice is presumed to have been received if mailed by first class to the last known address. There is a "presumption of receipt". However, the Personnel Office must be able to prove that the notice was sent in a manner that it is presumed to have been received or was reasonably calculated to be received by the qualified beneficiary. Reported non-compliance court cases generally conclude that, proof that the notice was mailed is more essential than, proof that the covered individuals actually received the notice.
  • Second and Third Class Mail: Although second and third class mail delivery (current postal terms are "Periodical and Standard Mail A") is acceptable, these postal classes do not provide the same guarantees regarding forwarding and return of mail, as does first class mail. Based on these types of inconsistencies, the tested and court approved first class mail delivery is recommended.
 To prove that the notice was sent the Personnel Office should maintain a copy of the notice actually sent (reflecting the name(s) and address to which the notice was sent) and maintain evidence that the mailing practice was followed for each notice sent.
 
Hand Delivery
If the initial notice is provided to an employee by hand delivery, have the employee sign a statement acknowledging receipt of the notice. The initial notice can only be hand delivered to an employee and not to the employee's spouse, domestic partner, or dependent children. Hand delivery is not notification to a covered spouse, domestic partner, or dependent children. The Personnel Office is required to send a separate notice to the employee's spouse or domestic partner.
 
Electronic Delivery
If the disclosure requirements are satisfied and measures in place (including e-mail and other Internet based methods) that ensure actual receipt of the initial notice, then the use of electronic delivery is allowable. However, conditions which may not allow the use of electronic delivery include employees, former employees, covered spouses, domestic partners, or dependent children who do not have access to the department's system (Even in situations where the Personnel Office has obtained permission from the employee, former employee, spouse, or domestic partner, to receive a notice at a particular home e-mail address, it cannot be assumed that they share an e-mail address).
 
Initial General COBRA Notice Log
The Initial General COBRA Notice Log is used to track the date and delivery method used to provide the notice. Refer to Attachment E - Sample Initial General COBRA Notice Log | Attachment E - Sample Initial General COBRA Notice Log - Text Only (RTF). You can also access this log as a fill and print document on the CalHR web site.
 

404. COBRA Qualifying Events

A "qualifying event" is an event that occurs which results in a loss of group coverage.

Qualifying Events and Length of Coverage

  • Voluntary or Involuntary Termination of Employment (for reasons other than gross misconduct) or Reduction of Hours (which causes loss of coverage)*: 18 months

  • Divorce or Legal Separation**: 36 months

  • Child Ceases to be a Dependent (e.g., child turns age 26): 36 months

  • Death of Employee***: 36 months

  • Employee Becomes Entitled to Medicare**** (under Part A, Part B, or both): 36 months

* Retirement is considered "Termination of employment"

* Reduction of hours includes:

  • Full-time to part-time, Strikes, Layoffs, Leaves of Absence (see Section 406), Permanent Intermittent Employee (who loses coverage based on a non-qualifying control period). Military call-up - 24 months of coverage (See "USERRA" Section 406).

** Termination of Domestic Partnership. The state will consider a covered domestic partner as a qualified beneficiary and may continue group coverage under COBRA.

** Annulment

*** 120-day death benefits apply, COBRA provisions are applicable after CalPERS determination of survivor benefits:

  • If CalPERS determines that family members are eligible for survivor benefits, then COBRA must be offered for vision coverage (since the survivors will be eligible to continue medical and dental benefits through CalPERS).

  • If CalPERS determines that family members are not eligible for survivor benefits, then COBRA must be offered for medical, dental, and vision benefits (since the survivors will not be eligible to continue medical, dental, and vision benefits through CalPERS).

The COBRA qualifying event is "death of employee", and the COBRA election notice and form must be sent within 14 days from the date that the 120-day death benefit ends.

**** Active state employees do not lose their state-sponsored group dental and vision coverage at age 65 or entitlement to Medicare. The qualifying event "Medicare Entitlement" is listed under federal COBRA law. However, it will not have an effect on active employees state-sponsored dental and vision coverage. If a former state employee becomes covered under Medicare while enrolled in COBRA continuation coverage, then his/her COBRA coverage may be terminated. COBRA continuation coverage for any covered dependents will not terminate for this reason. You should also read special Medicare entitlement rule for dependents in section 412. Length of COBRA Coverage.

 All qualified beneficiaries are eligible for COBRA continuation coverage, and may elect COBRA continuation coverage if group coverage is loss under the following conditions:

Qualifying Events for Covered Employee
A covered employee can elect COBRA coverage if he/she loses group coverage because of any of the following reasons:
  1. A voluntary or involuntary termination of employment (for reasons other than gross misconduct); or
  2. A reduction of hours (which causes loss of coverage).
Qualifying Events for Covered Spouse or Domestic Partner
A covered spouse or domestic partner can elect COBRA coverage if he/she loses group coverage because of any of the following reasons:
  1. A voluntary or involuntary termination of employee's employment (for reasons other than gross misconduct);
  2. Reduction of employee's hours (which causes loss of coverage);
  3. The death of employee;
  4. Divorce, termination of domestic partnership, or legal separation from employee; or
  5. The employee becomes entitled to Medicare (under Part A, Part B, or both).
Qualifying Events for Covered Dependent Children
A covered dependent child can elect COBRA coverage if he/she loses group coverage because of any of the following reasons:
  1. A voluntary or involuntary termination of the employee's employment (for reasons other than gross misconduct);
  2. Reduction of employee's hours (which causes loss of coverage);
  3. The death of employee;
  4. Parents divorce, terminate domestic partnership, or legally separate;
  5. The employee becomes entitled to Medicare (under Part A, Part B, or both); or
  6. A child ceases to be a dependent (e.g., child turns 26, child marries).

405. Retiree Benefit Plan Alternate Coverage

When the terms and conditions of a retiree benefit plan is different than the terms and conditions that are in place for active employees, then the retiree plan is considered alternate coverage (an increase in required premiums; a reduction of benefits; and any other change in the terms or conditions of coverage). The COBRA statute requires an offer of COBRA continuation coverage in these situations.

Delta Dental PPO plus Premier

An excluded employee that is enrolled in Delta Dental PPO plus Premier Plan and receiving the enhanced level of coverage will be automatically moved to the basic level of coverage when the dental enrollment form is processed at CalPERS. As a result, the retiree benefit plan is considered alternate coverage and COBRA continuation coverage is offered for the Delta Dental PPO plus Premier enhanced plan. The retiring employee (and qualified beneficiaries) may not want to elect continuation coverage and pay 102% of the group premium, when they can have Delta Dental PPO plus Premier Basic Plan benefits in retirement. However, the department cannot avoid its obligation to offer COBRA continuation in this situation. The alternate coverage provision will not have an effect on the Delta Dental PPO, SafeGuard, DeltaCare USA, Premier Access, and Western Dental plans.  

Vision Benefit COBRA offer upon Retirement

The Personnel Office must offer retiring employees vision coverage through COBRA. The COBRA qualifying event is a voluntary or involuntary termination of employment.

Retiree Vision Program

Because the terms and conditions that are in place for active employees vision plan are different than the Retiree Vision Program, the Personnel Office must offer COBRA continuation coverage to retiring employees and their eligible dependents to continue their current vision plan. The COBRA qualifying event is a voluntary or involuntary termination of employment.

406. Leaves of Absence

Unpaid Leave of Absence

When an employee is on an unpaid leave of absence the deductions for benefits cease, at that time the option to direct pay to continue the monthly premiums is offered, not COBRA. If the leave results in a loss of group coverage, then it is a COBRA qualifying event of reduction in hours or termination of employment, and COBRA should be offered. In other words, if the employee does not return to pay status, then COBRA continuation coverage must be offered.

The qualified beneficiary will be required to pay retroactive COBRA premiums to cover the period from the date of loss of coverage with no break in coverage.

It is important to inform employees who go on a leave of absence under these circumstances that if he/she does not return to pay status, then retroactive COBRA continuation coverage will be offered.

Family and Medical Leave Act (FMLA)

The department is required to offer 18 months of COBRA coverage, measured from the date that group plan coverage ends. The COBRA qualifying event of reduction of hours or termination of employment should be determined on the last day that the FMLA leave ends and the employee does not return to pay status. COBRA continuation coverage will not be offered until group coverage is actually lost. It is important to inform employees who go on FMLA leave that if he/she does not return to pay status, then COBRA continuation coverage will be offered at the end of the FMLA leave. It is important to inform employees who go on FMLA leave that if he/she does not return to pay status, then COBRA continuation coverage will be offered at the end of the FMLA leave.

Uniform Services Employment and Reemployment Rights Act (USERRA)

The Uniform Services Employment and Reemployment Rights Act (USERRA) provides (COBRA-Like) group plan continuation coverage rights for employees who take a leave of absence for uniformed service (military call-up). This continuation coverage is different than continuation coverage offered under COBRA.

Under COBRA, the loss of group coverage due to a leave of absence allows continuation coverage for a maximum of 18 months. The "Veterans Benefits Improvement Act of 2004", extended the continuation of group coverage period under USERRA from 18 months to a maximum of 24 months. As a result of this extension, an employee who is called to uniformed service must be offered COBRA continuation coverage for a maximum of 24 months. This extension applies to both the employee and eligible dependents.

Keep in mind that State of California employees are covered under GC Section 19775.17, GC Section 19775.18, and Executive Order D-65-02, this provides a greater benefit than is required under USERRA or COBRA. With this understanding, the Personnel Office should be aware of this extension of continuation coverage enacted through the "Veterans Benefits Improvement Act of 2004". However, this extension will not impact the requirement to offer employees who take a leave of absence for uniformed service (military call-up) the option of continuing group plan coverage as directed in GC Section 19775.17, GC Section 19775.18, and Executive Order D-65-02.

 

407. Loss of Group Coverage in Anticipation of a Qualifying Event

State employees are permitted to delete their spouse, domestic partner, or dependent children from group coverage based on a voluntary action (e.g., move out of household, deletion during open enrollment, deletion outside open enrollment). These types of deletions are not COBRA qualifying events and COBRA should not be offered. However, if group coverage is lost or reduced in anticipation of a COBRA qualifying event (e.g., divorce, legal separation, termination of a domestic partnership), then COBRA coverage must be offered from the first day of the month following the COBRA qualifying event.
 
Example: After filing for divorce, legal separation, or termination of a domestic partnership the employee deletes his/her spouse, domestic partner, or dependent children from coverage because of a move out of household or voluntary deletion. In this situation, the deletion was done in "anticipation of a COBRA qualifying event" and therefore should not be allowed. COBRA coverage must be offered at the time of the qualifying event (divorce, legal separation, or termination of domestic partnership is finalized). Employees should inform personnel offices of these events, and are informed of this reporting requirement through the initial general notice.
 
In the event of deletion of the spouse, domestic partner, or dependent children in anticipation of a COBRA qualifying event, and after notification from a spouse, domestic partner, or dependent children that he/she was deleted from coverage in anticipation of a COBRA qualifying event, the employee should be informed by the personnel office that they have received knowledge of this action, and make arrangements to place the dependent(s) back on the employee's plan. The deleted spouse, domestic partner, or dependent children must be offered COBRA coverage at the time of the COBRA qualifying event.
 
Keep in mind that if an employee deleting spouse, domestic partner, or dependent children is doing so not in anticipation of a COBRA qualifying event, the employee would be allowed to re-enroll his/her dependent children in state-sponsored coverage during the next open enrollment period as with any other similarly situated employee.
 

408. COBRA Election Notice and Election Form

 
The Personnel Office is required to provide an election notice and election form notice to a covered employee, spouse, domestic partner, and covered dependent children (if any), of their right to elect COBRA continuation coverage.
 
Unlike the initial notice which provides a summary of the rights, options, and notification responsibilities under COBRA, the election notice informs covered individuals that they have rights to elect continuation coverage because they will no longer be covered under a group plan. The loss of coverage is resulting from a COBRA qualifying event. Therefore, under provisions of COBRA, all covered individuals have the right to continue coverage for a maximum of 18 or 36 months, depending on the qualifying event. Their COBRA election rights are detailed in the election notice.
 
Departments should customize the notice, depending on whether the event is for 18 or 36 months, employee is single, married, in a domestic partnership, have dependent children, or the notice is being sent to a former spouse, former domestic partner, or dependent child who has independent rights to elect COBRA coverage. You may also customize the notice to identify more than one benefit to which there is an enrollment in coverage (e.g., medical, dental, and vision).
 
The importance of the election notice cannot be understated. Should covered individuals lose group coverage in the future and later claim that they were not aware of their rights to elect COBRA and election period, then the Personnel Office will be able to support that covered individuals who lose coverage were sent an election notice which provided information on their election rights and election period.
 
Each covered person whether an employee, spouse, domestic partner, or dependent child has independent election rights. If the covered employee does not want to elect COBRA, then the covered spouse, domestic partner, or dependent child have independent rights to elect COBRA continuation coverage.
 
The COBRA Election Notice contains the following information:
  • Details of rights to elect COBRA continuation coverage and responsibilities
  • Outline of coverage/notification procedures/premium payment periods
  • A COBRA Election Form

 14-Day Notice Period

The COBRA Election Notice and Election Form must be provided to qualified beneficiaries within 14 days from the date of the qualifying event or loss of coverage.
 
The Election Form should be signed and returned to the Personnel Office by the date reflected in the Election Notice/Election Form to confirm that COBRA continuation coverage has been elected. If the election form is not returned by the date reflected in the notice/form, then all rights to elect COBRA continuation coverage will end.

 44-Day Notice Rule

The following information regarding the 44-day notice is provided to ensure that departments are aware of this provision within the COBRA statute. However, your department is not the Plan Administrator for the state's benefit programs which means the 44-day notice rule will not apply. To ensure compliance of the COBRA statute notice requirements, the Personnel Office must provide the COBRA Election Notice and Election Form to qualified beneficiaries within 14 days from the date of the qualifying event or loss of coverage.
 
Situation #1: Employer is also the Plan Administrator: When the employer is also the plan administrator, then the employer has a maximum of 44 days from the date of the qualifying event or loss of coverage to provide the election notice - 30 days as the employer plus 14 days as the plan administrator.
 
Situation #2: Plan Administrator is not the Employer: When the employer is not the plan administrator, then the employer has a maximum of 30 days to notify the plan administrator of a qualifying event or loss of coverage. After being notified by the employer, the plan administrator has a maximum of 14 days to provide the election notice.
 
Situation #3: Multi-Employer Plan Administrator: A multi-employer plan is a plan to which more than one employer is required to contribute, and is maintained pursuant to one or more collective bargaining agreements between employee organization(s) and the employers. In other words, a multi-employer plan covers employees of more than one employer.  When the plan is a multi-employer plan, then the election notice should be provided within 14 days from the date of the qualifying event or loss of coverage. Multi-employer plan administrators are allowed more than 14 days to provide the election notice, if specified in the plan rules.

 

Departments are advised that in order to utilize the 44-day notice rule, you must be both the employer and plan administrator. However, it may not be reasonable in every situation for an employer who also acts as plan administrator having the benefit of a full 44 days to provide an election notice. In some circumstances, the employer/administrator might be allowed only 14 days in which to provide the required COBRA notice. For example, one federal court case concluded that an employee that suffered from a chronic illness should not have to wait more than 14 days to be provided an election notice. This created a serious medical hardship for the employee, regardless of the fact that coverage was eventually made retroactive.

Single Notice Rule

A single notice sent first class mail to the last known address, is considered good faith compliance. The notice must be addressed to the employee, spouse and domestic partner. Notification to the covered spouse or domestic partner is deemed notification to the covered dependent children who reside at the same address (including any dependent children covered in the future). The parent or legal guardian of minor children can elect on their behalf. A separate notice is required when the Personnel Office is aware that qualified beneficiaries reside at a different address. Keep a copy in file of the actual notice sent.

Court Orders

If a Personnel Office receives notification of a qualifying event that requires an offer of continuation coverage to a child or spouse of an employee, then an election notice and election form must be sent.

Dependent Child: Send election notice and election form to the custodial parent or guardian ("in care of the child") or agency that provided notification of the qualifying event (as a substitute, if child's address is unknown).

Spouse: Send election notice and election form to the spouse or agency ("in care of the spouse") that provided notification of the qualifying event (as a substitute, if spouse's address is unknown).

Approved Notice Delivery Methods

The COBRA statute disclosure regulations require that notices must be furnished using "measures reasonably calculated to ensure actual receipt of the material". The following are examples of acceptable distribution methods (first-class, second- or third class mail, certified mail, hand-delivery, and electronic disclosure).

 Mail Delivery
  • First Class Mail: First class mail is the evidentiary requirement. Proof of receipt is not required. A notice is presumed to have been received if mailed by first class mail to the last known address. There is a "presumption of receipt". However, the Personnel Office must be able to prove that the notice was sent in a manner that it is presumed to have been received or was reasonably calculated to be received by the qualified beneficiary. Reported non-compliance court cases generally conclude that, proof that the notice was mailed is more essential than, proof that the qualified beneficiary actually received the notice.
  • Second and Third Class Mail: Although second and third class mail delivery (current postal terms are "Periodical and Standard Mail A") is acceptable, these postal classes do not provide the same guarantees regarding forwarding and return of mail, as does first class mail. Based on these types of inconsistencies, the tested and court approved first class mail delivery is recommended.
  • Certified Mail with No Return Receipt or First Class Mail with a Certificate of Mailing: Certified Mail with No Return Receipt or First Class Mail with a Certificate of Mailing (with post office date stamp) is recommended, but not required. Departments should be aware that Certified Mail Delivery with Return Receipt might cause problems when determining the 60-day election period. As explained above, the Personnel Office is required to prove that the notice was mailed, not its receipt.

To prove that the notice was sent, the Personnel Office should maintain a copy of the notice actually sent (reflecting the name and address where the notice was sent) and maintain evidence that the mailing practice was followed for each notice sent.

Hand Delivery

If the election notice is provided to an employee by hand delivery, have the employee sign a statement acknowledging receipt of the notice. The election notice can only be hand delivered to an employee and not to the employee's spouse, domestic partner, or dependent children. Hand delivery is not notification to a covered spouse, domestic partner, or dependent children. The Personnel Office is required to send a separate notice to the employee's spouse or domestic partner.

 

Electronic Delivery

If the disclosure requirements are satisfied and measures in place (including e-mail and other Internet based methods) that ensure actual receipt of the initial notice, then the use of electronic delivery is allowable. However, conditions which may not allow the use of electronic delivery include employees, former employees, covered spouses, domestic partners, or dependent children who do not have access to the department's system (Even in situations where the Personnel Office has obtained permission from the employee, former employee, spouse, or domestic partner, to receive a notice at a particular home e-mail address, it cannot be assumed that they share an e-mail address).

COBRA Election Notice Log

The COBRA Election Notice Log is used to track the date and delivery method used to provide the notice. Refer to Attachment F - COBRA Election Notice Log | Attachment F - COBRA Election Notice Log - Text Only (RTF). You can access this log as a fill and print document on the CalHR web site.

 

409. COBRA Qualifying Event Notification Responsibilities

Personnel Office

The Personnel Office has responsibility to ensure that covered employees, spouses, domestic partners, and dependent children (also known as "qualified beneficiaries") are advised of their COBRA rights and responsibilities, provide required notices, and monitor timelines for COBRA elections and coverage continuation periods.

The Personnel Office should be aware of when a covered employee has died, voluntary or involuntary termination of employment, or reduction of hours. At the time that one of these qualifying events occurs, a COBRA Election Notice and Election Form must be provided to qualified beneficiaries within 14 days from the date of the qualifying event or loss of coverage.

 

Employee, Spouse, and Domestic Partner

The covered employee, spouse, and domestic partner has responsibility to notify the Personnel Office when a divorce, termination of domestic partnership, legal separation, or a child ceases to be a dependent occurs (e.g., child turns 26, child marries). At the time that one of these qualifying events occurs, the Personnel Office must receive notification within 60 days from the date of the qualifying event or the date on which coverage is lost. If notification is provided timely, then a COBRA Election Notice and Election Form must be provided to qualified beneficiaries within 14 days from the date of the qualifying event or loss of coverage. This notice is sent to qualified beneficiaries to explain their rights to elect COBRA continuation group coverage.

If notice to the Personnel Office, is not provided timely, then the department is not required to offer COBRA continuation coverage. You should refer to Section 407, "Notice of Unavailability of Continuation Coverage", regarding the required notice when continuation coverage will not be offered.

Although it is the employees, spouses, and domestic partners responsibility to notify the Personnel Office when a child ceases to be a dependent, you may be aware that a COBRA qualifying event has occurred (e.g., child turns 26). If the Personnel Office is aware that a qualifying event has occurred, then a COBRA Election Notice and Election Form must be provided to the qualified beneficiaries.

410. Notice of Unavailability of Continuation Coverage

The Notice of Unavailability of Continuation Coverage Notice is the third of three required COBRA notices. In the event that the Personnel Office is notified of a qualifying event and determines that an individual is not entitled to elect continuation coverage, (i.e., 60-day notification period missed) the Personnel Office must provide a "Notice of Unavailability of Continuation Coverage", within 14 days to explain why the individual is not entitled to elect continuation coverage. Keep a copy in file of the actual notice sent. Refer to Attachment D - Sample Notice of Unavailability of Continuation Coverage | Attachment D - Sample Notice of Unavailability of Continuation Coverage - Text Only (RTF).

Monthly COBRA Status Report

The Monthly COBRA Status Report is used to track the number of notices sent, types of qualifying events, and number of COBRA enrollments. Refer to Attachment G - Sample Monthly COBRA Status Report | Attachment G - Sample Monthly COBRA Status Report - Text Only (RTF). You can access this report as a fill and print document on the CalHR web site.

411. Election Period

Each qualified beneficiary will have 60 days from the date of loss of coverage or 60 days from the date of the COBRA Election Notice to elect COBRA continuation coverage, whichever date is later. Each qualified beneficiary has independent election rights. The two examples shown on the next page illustrate how the election period works in the case of a qualified beneficiary who has lost group coverage. These dates may be different. The Personnel Office must identify the last date to elect COBRA continuation coverage on the Election Notice.
 
If an election period ends on a Saturday, Sunday, or Holiday, then the election period will be extended to the next regular workday.

Example #1 Loss of Coverage Date Being Later

  • Date of Termination: 1-22-17
  • Date of Notice: 2-1-17
  • Date of Loss of Coverage: 2-28-17
  • End of Election Period: 4-29-17

Example #2 COBRA Notice Date Being Later

  • Date of Termination: 1-22-17
  • Date of Loss of Coverage: 2-28-17
  • Date of Notice: 3-5-17
  • End of Election Period: 5-4-17

No Coverage During COBRA Election Period

The qualified beneficiaries are not covered under the plan during the election period. Any claim for services occurring on or after the date group coverage ceases will not be paid. However, if COBRA is elected and retroactive premiums are paid as detailed in section 413, COBRA Premiums, then coverage will be retroactive back to the date coverage ceased and any claim for services occurring on or after that date will be processed.

Tolling of COBRA Timelines

COBRA allows for the termination of COBRA rights in the event a qualified beneficiary fails to elect COBRA coverage within the required election period. However, if a qualified beneficiary is mentally or physically incapacitated to the extent that the person cannot complete the required action, then the COBRA timelines will be "tolled." This means that the specific timeline is put on hold until during the period of the incapacity or a guardian can be named to act on behalf of the beneficiary. Each case must be evaluated on its own merits and legal counsel should be consulted prior to a decision being made.

The guidelines set forth in the following chart are based on when the Personnel Office is first aware of a qualifying COBRA event as reflected in section 404. COBRA Qualifying Events

412. Length of COBRA Coverage

COBRA provides two basic maximum periods of coverage for each type of qualifying event. The two maximum periods specified are 18 or 36 months. The

following outlines the qualifying events and maximum length of continuation coverage.

COBRA Coverage 18 Months

If the qualifying event causing the loss of coverage is a voluntary or involuntary termination of employment (other than for reasons of gross misconduct) or a reduction of hours (which results in a loss of coverage), then each qualified beneficiary will have the opportunity to continue coverage for 18 months from the date of the loss of coverage.

Social Security Disability Extension to the 18-Month Period

The 18 months of continuation coverage can be extended for an additional 11 months of coverage, to a maximum of 29 months for all qualified beneficiaries if the Social Security Administration determines a qualified beneficiary was disabled according to Title II or XVI of the Social Security Act at the time of the qualifying event or any time during the first 60 days 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. It is also the qualified beneficiaries responsibility to notify the plan within 30 days if a final determination has been made that they are no longer disabled.

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.

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.

SB 761 - Former State Employee Extension to the 18-Month Period (Repealed Effective January 1, 2005)

Another extension to the 18-month continuation period is available to any former State of California employee currently enrolled in COBRA and he/she was 60 years of age and an active employee for at least five prior years on the date that his/her employment ended. The extended COBRA period will provide uninterrupted coverage until age 65 or entitlement to Medicare. The spouse or domestic partner may extend the coverage for a period of five years from the date that the former employee's employment ends. Premiums for extended coverage for former employees beyond the initial 18 months will be calculated at 213% of the state's group coverage premium rate and will continue to be paid monthly directly to the plan or its designee.

To elect, the former employee, spouse, or domestic partner must notify the plan within 30 days prior to the end of the 18-month COBRA coverage period.

AB 254 Repeals SB 761 - Former State Employee Extension to the 18-Month Period

Under California law employer-sponsored medical plans the provisions of SB 761 were repealed for those individuals who meet the eligibility requirements of SB 761 after January 1, 2005. What this means is that if an employee experiences a qualifying event (i.e., termination of employment) on or after January 1, 2005, then the provisions of SB 761 are not available at the end of the 18-month COBRA continuation coverage.
 

AB 1401 - Extension of the Minimum COBRA Coverage Period

Under this California law, employer-sponsored medical plans must allow an extension to COBRA coverage for an enrollee who has exhausted their initial 18 month continuation coverage period for up to 36 months from the date that coverage began. This provision will only apply to continuation of medical insurance COBRA coverage. In no event will continuation coverage last beyond three years (36 months) from the original date of loss of coverage. Premiums for extended coverage for former employees beyond the initial 18 months will be calculated at 110% of the state's group coverage premium rate and will continue to be paid monthly directly to the plan or its designee.

Secondary COBRA Event occurs during the 18-Month Period

If during the 18 months of continuation coverage, a second event takes place (divorce, termination of domestic partnership, legal separation, death, or a dependent child ceases to be a dependent), then the original 18 months of continuation coverage can be extended to 36 months from the original date of loss of coverage for eligible dependent qualified beneficiaries. If a second event occurs, it is the qualified beneficiary's responsibility to notify the plan in writing within 60 days of the second event and within the original 18-month COBRA timeline.

In no event will continuation coverage last beyond three years (36 months) from the original date of loss of coverage. A reduction in hours followed by a voluntary or involuntary termination of employment is not considered a second COBRA timeline.

COBRA Coverage 36 Months

If the original qualifying event causing the loss of coverage was the death of the employee, divorce, termination of domestic partnership, legal separation, or child ceases to be a dependent (e.g., child turns age 26, child marries), then each qualified beneficiary will have the opportunity to continue coverage for 36 months from the date of his/her loss of coverage.

COBRA Calendar

The COBRA calendar will provide the date that COBRA continuation coverage ends based on the effective date of the 18 or 36 month coverage period. Refer to Attachment H - COBRA Calendar. You can access this calendar on the CalHR web site.
 

413. COBRA Premiums

Premium Payment

If COBRA is elected, the cost for coverage will be 100% of the total premium, plus a 2% administration fee which is paid monthly by the enrollee to the plan or its designee. The plan or its designee is not required to send a monthly bill. The department is not required to pay a share of the COBRA premium. (Refer to section 420. Dental/Vision COBRA Premiums, for premium rates and section 421. Insurance Plan Addresses and Phone Numbers, for plan names and addresses.) If there is a change in future premium rates, then departments and enrollees will be notified as soon as possible prior to the new premiums going into effect.

Retroactive Premium Payment

Once COBRA is elected, the enrollee has 45 calendar days from the date of election to pay all retroactive premiums to the plan or its designee. The retroactive premium payment is the premium to cover the period from the date of loss of coverage to the date of election. All claims occurring during the months of retroactivity will be held pending premium payment being made.

Calculating the 45-Day Retroactive Premium Payment Period

The outline below illustrates how the 45-day retroactive COBRA premium payment period works in the case of a qualified beneficiary whose employment terminates on May 17 and coverage is provided through the end of the next month. If the employee elects COBRA on August 4th, then the retroactive premium payment is not due until 45 days later (September 18).

May 17th
  • Qualifying Event (Termination of Employement)
July 1st
  • First day of COBRA coverage
  • Premium covers this period
August 2nd
  • Elect COBRA coverage
  • 45 days start
  • Premium covers this period

August 31st

  • 45 days continues
  • Premium covers this period

September 18th

  • Premium for period from July 1st through August 31st
  • 45 days end
  • Premium does not cover this period
Although the September premium is due by the first day of the month, there is a 30-day grace period for the premium due by September 1.
 
If the 45-day retroactive premium due date ends on a Saturday, Sunday, or Holiday, then the due date will be extended to the next regular workday.
 

Future Monthly Premium

Once the retroactive premium is paid, future monthly premiums are due by the first of each following month. While due on the first, the enrollee will have a maximum thirty (30) day grace period following the due date in which to make these premium payments. All claims occurring during the month will be held pending premium payment being made. If the applicable payment is not made within the grace period, then coverage will be cancelled back to the end of the prior month in which a premium payment had been made. Once COBRA coverage is cancelled due to nonpayment of COBRA premiums the enrollee will not be reinstated.

Tolling of COBRA Payment Timeline

COBRA allows for the termination of COBRA coverage in the event an enrollee fails to pay a premium within the required payment period. However, if the enrollee is mentally or physically incapacitated to the extent that the person cannot pay the required premium, then the COBRA payment timeline will be "tolled". This means that the specific timeline is put on hold during the period of the incapacity or a guardian can be named to act on behalf of the enrollee. Each case will be evaluated on its own merits by the plan or its designee.

  

Partial Premium Payment Not Significantly Less

If the plan receives a partial monthly premium that is not significantly less than the premium due, then the plan or its designee will notify the enrollee of the amount of the deficient and allow a 30-day period for payment of the deficiency amount. All claims occurring during the month will be held pending receipt of the deficient amount. An amount is not significantly less, if the deficit is not greater than the lesser of the following two amounts:

(1) Fifty dollars ($50) or (2) 10 percent (10%) of the amount due.

 

Example: The amount due is $250 per month. The plan receives a COBRA payment of $230. The payment is $20 less than the premium due.

Result: Since the deficit ($20) is less than $50 or 10% of the amount due ($25), then the payment ($230) is not significantly less and the enrollee will be given a 30-day period for payment of the deficient amount.

Health Insurance Premium Payment (HIPP) Program

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: HIPP@dhcs.ca.gov or by fax at 916-440-5676.

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: HIPP@dhcs.ca.gov or by fax at 916-440-5676. 

414. Gross Misconduct

If the termination from employment is due to "gross misconduct", then the department should not offer COBRA coverage. While providing this exception to offering COBRA, the statute and IRS have not provided a definition for employers to use. However, if a department wants to utilize the gross misconduct exception, you should draft a written policy that will serve as the basis for your decision on what will constitute gross misconduct. It is very important that your employees are made aware of what type of actions would constitute a gross misconduct termination.
 
Keep in mind that when a covered employee is terminated for gross misconduct, there is no qualifying event for the covered employee, spouse, domestic partner, or dependent children. None of these individuals are offered COBRA. It is recommended that the Personnel Office send a letter to qualified beneficiaries stating that COBRA coverage will not be offered.
 
Although there is not a common standard to apply in gross misconduct cases, one federal court fashioned the following definition of gross misconduct:
  • Gross misconduct may be intentional, wanton, willful, deliberate, reckless or in deliberate indifference to the employer's interest. It is misconduct beyond mere minor breaches of employee standards, but conduct which would be considered gross in nature.
The following information can also assist you in determining gross misconduct cases:
  • Written Policy: Is there a written policy in your department that described the actions that would constitute gross misconduct? Was the employee made aware?
  • Employee History: What type of employment history did the employee have at the department? Was the reason for termination a recurrent problem?
  • Violation of Law: Did the employee violate a federal, state or local law? Has the employee been charged in criminal court? Has the employee admitted the violation?
  • State Unemployment Compensation Disqualification Based on Gross Misconduct: A description of reasons to disqualify former employees from collecting unemployment compensation is identified in the California State Unemployment Insurance Law.
  • Consult Legal Counsel: Legal counsel should review the reasons for termination and assist in the gross misconduct decision making process.
A gross misconduct decision should not be based upon a single event described above, but totality of the facts and circumstances associated with the employee.
 

415. Noncompliance Penalties and Fines

Departments are responsible for ensuring that covered employees and covered dependents are provided with COBRA information, required notices, and assistance in completing enrollment forms. Departments should not make judgments or decisions independent of the COBRA law. IRS has authority to audit COBRA Programs. Departments are subject to audits and fines imposed by the Internal Revenue Service (IRS) Excise Tax, and subject to lawsuits under the Employee Retirement Income Security Act (ERISA), and Public Health Service Act (PHSA) for failure to comply with COBRA requirements.
 
Departments may want to ensure that the following items are maintained and/or accomplished to limit the prospect of COBRA violations:
  • Train staff on COBRA law
  • Maintain internal COBRA standard operating procedures
  • Maintain copies of COBRA notices
  • Audit Program

Statute of Limitations

There is no expressed statute of limitation on COBRA violations. Departments are advised that a normal six-year period to maintain COBRA documentation is recommended based on laws applicable to claims for economic damages.
 

416. Open Enrollment Period

COBRA enrollees have the same rights as active employees to make allowable changes to their coverage during the annual open enrollment period. This information is communicated in the Initial and Election notices. Specific instructions will be sent to all COBRA enrollees by CalHR prior to the beginning of the open enrollment period. The effective date of any action during open enrollment is January 1, of the following year.
 
If covered active employees add a spouse, domestic partner, and/or dependent children to their coverage during an open enrollment period, the Personnel Office is required to provide an Initial General COBRA Notice to the newly covered spouse or domestic partner. Keep in mind that notification to the covered spouse or domestic partner is deemed notification to the covered dependent children (if any).
  

417. COBRA in Retirement

If a former spouse, domestic partner, or dependent child of a retired state employee experiences a COBRA qualifying event he/she will be offered COBRA continuation coverage through CalPERS. CalPERS retirees and their eligible dependents should contact CalPERS Health Benefit Services Division regarding COBRA notices and enrollment options.
  

418. Loss of COBRA Continuation Coverage

COBRA continuation coverage will cease for a COBRA enrollee if one of the events listed below occurs prior to the expiration of the 18 or 36 month COBRA period. The state does not offer any type of conversion plan after the 18 or 36 month COBRA coverage period expires. The enrollee should contact the plan directly for information about an individual conversion plan.
  • Employer ceases to provide group coverage plans;
  • Failure to pay timely required premiums;
  • A qualified beneficiary becomes covered under another employer's plan that does not contain any exclusion or limitation with respect to any preexisting health condition;
  • A qualified beneficiary extended continuation coverage to 29 months due to a Social Security approved disability and a final determination has been made that the qualified beneficiary is no longer disabled;
  • A qualified beneficiary notifies the plan they wish to cancel continuation coverage;
  • A qualified beneficiary becomes covered under Medicare while enrolled in continuation coverage; or
  • For cause, on the same basis that the plan terminates the coverage of similarly situated non-COBRA participants.
All termination of COBRA coverage notices will be provided by the plan.
  

419. Completion of COBRA Enrollment Forms

Delta Dental Plans - Delta Premier and Delta Preferred Provider Option (PPO)

The Dental Plan Enrollment Authorization (STD. 692) will serve as the COBRA Continuation Enrollment Form for all COBRA enrollments in the Delta Premier and Delta Preferred Provider Option (PPO) plans. Instructions are provided below. The Personnel Office should contact the eligible employee, spouse, or domestic partner to obtain the information necessary to complete the form.

Wolfpack Insurance Services, Inc., a company that provides administrative COBRA services, handles COBRA enrollments for Delta Dental (Delta).

Note: Dependents of rank and file employees have a lower level of coverage under the Delta Premier - Basic Plan and pay a lower COBRA premium for dependent only coverage. The Personnel Office should reflect the dependent only COBRA premium when completing the STD. 692.

PrePaid Dental Plans - DeltaCare USA, SafeGuard, Premier Access, and Western Dental

The Dental Plan Enrollment Authorization (STD. 692) will serve as the COBRA Continuation Enrollment Form for all COBRA enrollments in the DeltaCare USA , SafeGuard, Premier Access and Western Dental plans. Instructions are provided below. The Personnel Office should contact the eligible employee, spouse, or domestic partner, to obtain the information necessary to complete the form.

Wolfpack Insurance Services, Inc., a company that provides administrative COBRA services, handles COBRA enrollments for DeltaCare USA. SafeGuard, Premier Access and Western Dental, handles the COBRA enrollments for their enrollees.

Bargaining Unit 5

For employees in Bargaining Unit 5, COBRA enrollment forms for dental coverage should be sent to the California Association of Highway Patrolmen (CAHP) Dental Trust. Contact CAHP for COBRA dental premiums information. Unit 5 employees have vision coverage through the state-sponsored Vision Service Plan (VSP) and COBRA enrollments for their vision coverage should be sent to the vision plan.
 

Bargaining Unit 6

For employees in Bargaining Unit 6, COBRA enrollment forms should be sent to the California Correctional Peace Officers Association (CCPOA) Benefit Trust. Personnel Offices should assist employees, spouses, domestic partners, and dependent children with the completion of the COBRA enrollment forms and submit forms to CCPOA. Contact CCPOA for COBRA dental and vision premium information.

Telephone numbers and mailing addresses

Telephone numbers and mailing addresses are listed in section 421. Insurance Plan Addresses and Phone Numbers. Do not send the COBRA enrollment forms or premium payments to CalHR, SCO, or CalPERS.
 

Instructions for completion of the STD. 692 - COBRA:

Section A:
  • A1. Check COBRA Box.
  • A2 - A6. Enter the name, address, marital status, sex, and social security number of the eligible enrollee.
  • A7. Enter spouse's or domestic partner's social security number.
Section B:
  • B1 - B2. Enter name of dental plan (e.g., Delta Premier-Enhanced, Delta Premier-Basic, Delta Premier-Basic - Dependent Only, Delta Preferred Provider Option (PPO), DeltaCare USA, SafeGuard-Standard, or SafeGuard-Enhanced), Premier Access and Western Dental . For Bargaining Units 5 and 6 employees, reflect the appropriate dental plan name. Enter provider/facility number, if applicable.
  • B3. List all persons to be enrolled (include self).
Section D:
  • D2 - D3. Enrollee's signature/date required.
Section E:
  • E-9 Enter the total monthly premium to be paid by the eligible enrollee.
  • E-12 Enter the date of the qualifying event (e.g. divorce, termination of domestic partnership, termination from employment, child ceases to be a dependent).
  • E-14 Enter effective date of action (the first day of the month after loss of coverage).
  • E-17 Enter state employee's agency name.
  • E-18 Enter the qualifying event (e.g. divorce, termination of domestic partnership, termination from employment, child ceases to be a dependent). If the enrollee is not the employee, then enter the name and social security number of the employee. Provide a telephone number if available.
  • E-19 Signature of authorized agency representative.
  • E-20 Telephone number of authorized agency representative.
  • E-21 Enter date completed.
If the employee elects coverage and enrolls his/her family members at the same time, then only one form listing all family members is needed. Retain the agency copy (pink copy) of the completed STD. 692 in the employee's personnel file and send the original (white copy) and plan copy (yellow copy) to the plan or its designee. The green copy of the STD. 692 should be sent to the enrollee. Do not send the original or copy to CalHR, SCO, or CalPERS.

Vision Coverage

The Vision Plan Enrollment Authorization (STD. 700) will serve as the COBRA Continuation Enrollment Form for all COBRA enrollments in the vision plan. Instructions are provided below. The Personnel Office should contact the eligible employee, spouse, or domestic partner, to obtain the information necessary to complete the form. For Bargaining Units 5 and 6 employees, reflect the appropriate vision plan name.

Instructions for completion of the STD. 700 - COBRA:

 
Section A:
  • A1 - A6. Enter the social security number, date of birth, martial status, sex, name, and address of the eligible enrollee.
  • A7. Check COBRA Box.
  • A8 - A10. Enter spouse's or domestic partner's name, social security number, and date of birth.
  • A11 - A22. List all other family members to be enrolled (if more members than space available, then attach an additional form).
Section B:
  • B1 - B2. Enter name of vision plan. Enter provider/facility number, if applicable.
Section D:
  • D1. Enrollee's signature/date required.
Section E:
  • E-6 Enter effective date of action (the first day of the month after loss of coverage).
  • E-9 Enter the total monthly premium to be paid by the eligible enrollee.
  • E-10 Enter the date of the qualifying event (e.g. divorce, termination of domestic partnership, termination from employment, child ceases to be a dependent).
  • E-14 Enter state employee's agency name.
  • E-15 Enter the qualifying event (e.g. divorce, termination of domestic partnership, termination from employment, child ceases to be a dependent). If the enrollee is not the employee, then enter the name and social security number of the employee. Provide a telephone number if available.
  • E-17 Signature of authorized agency representative.
  • E-18 Telephone number of authorized agency representative.
  • E-19 Enter date completed.
If the employee elects coverage, then all family members are enrolled at the same time and only one form is needed. Retain the agency copy (pink copy) of the completed STD. 700 in the employee's personnel file and mail the original (white copy) to the plan or its designee. The goldenrod copy of the STD. 700 should be sent to the enrollee. Do not send the original or copy to CalHR, SCO, or CalPERS.
 

Instructions for completion of the CalHR 774 - COBRA:

The CALHR 774 will be available as fill and print on CalHR web site.   

The form is available on CalHR web site
 
1. Complete Section A: Enter the name, MyCalPays ID (if applicable), social security number, and date of birth, phone number, email and mailing address of the eligible   employee.Check the appropriate box to elect to enroll (New COBRA Enrollment).
2. Complete Section B: Enter dependent information including whether dependent is being added or deleted; if there are no dependents, skip Section B and go to Section C.
3. Complete Section C: Employee must sign and date the bottom of Section C. No need to check box in this section.
4. Complete Section D: This section to be completed by Employing Agency only.
• D-1: Enter the deduction code
• D-2: Enter party code (1-member only, 2-member plus one dependent, 3-member plus two or more dependents).
• D-3: Enter premium deduction amount. (should show full amount of COBRA premium based on party code) 
• D-4: Enter effective enrollment.
• D-5: Enter BU/CBID
• D-6: Enter permitting event date.
• D-7: Enter permitting event code as none or leave blank
• D-8: Enter agency name, unit code, and agency code.
• D-9: Enter any remarks - enter separation date (and retirement date if applicable)
• D-10: Enter agency area code and telephone number.
• D-11: Enter date of agency signature.
• D-12: Enter agency phone number and email. Sign name of authorized agency signature.
• D-13: One copy should be retained in agency file, one copy should go to the employee.

Please mail completed CalHR 774 form to VSP's mailing address or fax to VSP at (916) 463-9031 for processing. See Section 421 for address to send the CalHR 774 to vision carrier.
 

420. Dental/Vision COBRA Premiums

COBRA Premiums Effective as of January 1, 2017

Dental Plans

 

Benefit: Delta Dental PPO plus Premier Enhanced Plan (Excluded employees and their dependents)
Employee Only: $55.65
Employee & 1 Dep.: $109.89
Employee & 2+ Deps.: $154.51
 
Benefit: Delta Dental PPO plus Premier Basic (Rank and file employees)
Employee Only: $53.49
Employee & 1 Dep.: $93.67
Employee & 2+ Deps.: $135.55
 
Benefit: Delta Dental PPO plus Premier Basic (Dependents of rank and file employees*)
Employee Only: $45.88
Employee & 1 Dep.: $68.76
Employee & 2+ Deps.: $89.91
 
Benefit: Delta Dental Preferred Provider Option (Rank and file and excluded employees and their dependents)
Employee Only: $48.84
Employee & 1 Dep.: $95.31
Employee & 2+ Deps.: $143.61
 
Benefit: DeltaCare USA (Rank and File and Excluded employees and their dependents)
Employee Only: $19.25
Employee & 1 Dep.: $31.59
Employee & 2+ Deps.: $43.70
 
Benefit: SafeGuard Standard (Rank and File employees and their dependents)
Employee Only: $16.91
Employee & 1 Dep.: $27.40
Employee & 2+ Deps.: $38.37
 
Benefit: SafeGuard Enhanced (Excluded employees and their dependents)
Employee Only: $17.26
Employee & 1 Dep.: $29.20
Employee & 2+ Deps.: $35.98
 
Benefit: Premier Access (Excluded and Rank and File employees and their dependents)
Employee Only: $16.12
Employee & 1 Dep.: $26.10
Employee & 2+ Deps.: $36.56
 
Benefit: Western Dental (Excluded and Rank and File employees and their dependents)
Employee Only: $15.46
Employee & 1 Dep.: $25.52
Employee & 2+ Deps.: $36.20
  

Vision Plans

Benefit: Vision Service Plan (VSP)
Basic Vision Plan
Employee Only: $8.81
Employee & 1 Dep.: $8.81
Employee & 2+ Deps.: $8.81
 
Premier Vision Plan
Employee Only: $17.83
Employee & 1 Dep.: $26.85
Employee & 2+ Deps.: $37.84

Annuitant Basic Vision Plan
Employee Only: $7.68
Employee & 1 Dep.: $14.91
Employee & 2+ Deps.: $16.04

Annuitant Premier Vision Plan
Employee Only: $20.81
Employee & 1 Dep.: $41.16
Employee & 2+ Deps.: $44.77

 
 
 
*Dependents of rank and file employees have a lower level of coverage under the Delta Premier - Basic Plan and pay a lower premium for dependent only coverage.
 
For Bargaining Unit 5 employees, contact CAHP for dental premiums information. Unit 5 employees have vision coverage through Vision Service Plan (VSP) and the vision premiums that are reflected above apply. For Bargaining Unit 6 employees, contact CCPOA for dental and vision premiums information.

  

421. Insurance Plan Addresses and Phone Numbers

Send Enrollment forms and premium payments to the following addresses:
 

Delta Dental Plans

For Delta Premier and Delta Preferred Provider (PPO) enrollees, send the STD. 692 and premium payments to:
 
Wolfpack Insurance Services, Inc.
P.O. Box 833
Belmont, CA 94002-0833
Attn: COBRA - State of California
1-800-296-0192
You may also fax the STD. 692 to (650) 591-4022
 

Pre-Paid Dental Plans

For DeltaCare USA enrollees, send the STD. 692 and premium payments to:
 
Wolfpack Insurance Services, Inc.
P.O. Box 833
Belmont, CA 94002-0833
Attn: COBRA - State of California
1-800-296-0192
You may also fax the STD. 692 to (650) 591-4022
 
SafeGuard Health Plans
MetLife Benefits
Attn: COBRA Billing
P.O. Box 13724
Philadelphia, PA 19101
Benefit Questions 1-800-880-1800
Billing Questions (949) 471-2283
 
Premier Access
8890 Cal Center Drive
Sacramento, CA 95826
Attn: COBRA UNIT
1-888-534-3466
 
Western Dental
530 South Main Street, 6th Floor
Orange, CA 92868
Attn: COBRA UNIT
1-866-859-7525
  

Union Trust Dental Plans

Unit 6
 
CCPOA Benefit Trust Fund
2515 Venture Oaks Way, Suite 200
Sacramento, CA 95833
1-800-468-6486
  
Unit 5 (Dental enrollments only)
 
CAHP Dental Trust
2030 V Street
Sacramento, CA 95818
1-800-734-2247
 

Vision Plan

VSP
Attn: COBRA UNIT - Mailstop 229
P.O. Box 997100
Sacramento, CA 95899-7100
You may also fax the STD. 700 to (916) 463-9031 Ext.4636
1-800-852-7600
  Updated: 12/28/2016
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