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32BJ North Health Fund

Tri-State Preferred North Summary Plan Description (SPD) >> Continued Group Health Coverage

During a Family and Medical Leave ALERT: 3/21/2012 NEW Click here for important benefit changes>>
During Military Leave
Under COBRA ALERT: 3/21/2012 NEW Click here for important benefit changes>>
COBRA Continuation of Coverage ALERT: 3/21/2012 NEW Click here for important benefit changes>>

During a Family and Medical Leave

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The Family and Medical Leave Act (FMLA) allows up to 12 weeks of unpaid leave during any 12-month period due to:

the birth, adoption or placement with you for adoption of a child
to provide care for a spouse, child or parent who is seriously ill, or
your own serious illness.

During FMLA leave, you can continue all of your medical coverage and other benefits offered through the Plan. You are generally eligible for a leave under the FMLA if you:

have worked for the same contributing employer for at least 12 months
have worked at least 1,250 hours over the previous 12 months, and
work at a location where at least 50 employees are employed by the employer within 75 miles.

Check with your employer to determine if you are eligible for FMLA.

The Fund will maintain the employee’s eligibility status until the end of the leave, provided the contributing employer properly grants the leave under the FMLA and the contributing employer makes the required notification and payment to the Fund. Of course, any changes in the Plan’s terms, rules or practices that go into effect while you are away on leave apply to you and your dependents, the same as to active employees and their dependents. Call the Fund Office regarding coverage during FMLA leave.

During Military Leave

If you are on active military duty for 31 days or less, you will continue to receive medical coverage in accordance with the Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA). If you are on active duty for more than 31 days, USERRA permits you to continue medical and dental coverage for you and your dependents at your own expense for up to 24 months provided you enroll for coverage. This continuation coverage operates in the same way as COBRA. (See the "Continued Group Health Coverage" section for information on COBRA.) In addition, your dependents may be eligible for health care under the Civilian Health & Medical Program of the Uniformed Services (TRI-CARE). This Plan will coordinate coverage with TRI-CARE (see the "Coordination of Benefits" section).

When you return to work after receiving an honorable discharge, your full eligibility will be reinstated on the day you return to work with a participating employer, provided that you return to employment within one of the following time frames:

90 days from the date of discharge if the period of military service is more than 180 days
14 days from the date of discharge if the period of military service was 31 days or more, but less than 180 days
at the beginning of the first full regularly scheduled working period on the first calendar day following discharge (plus travel time and additional eight hours) if the period of service was less than 31 days.

If you are hospitalized or convalescing from an injury resulting from active duty, these time limits may be extended for up to two years. Contact the Fund Office for more details.

Under COBRA

ALERT: 3/21/2012 NEW Click here for important benefit changes>>

Under a Federal law called the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA), group health plans are required to offer temporary continuation of health coverage, on an employee-pay-all basis, in certain situations when coverage would otherwise end. “Health coverage” includes the Fund’s hospital, medical, EAP, dental, prescription drug and vision coverage.

You do not have to prove that you are in good health to choose COBRA continuation coverage — but you do have to meet the Plan’s COBRA eligibility requirements and you must apply for coverage. The Fund reserves the right to end your COBRA coverage retroactively if you are determined to be ineligible.

The following chart shows when you and your eligible dependents may qualify for continued coverage under COBRA, and how long your coverage may continue. Please keep in mind that the following information is a summary of the law and is, therefore, general in nature. If you have any questions about COBRA, please contact the Fund Office.

COBRA Continuation of Coverage

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Coverage May Continue For:	If:	Maximum Duration of Coverage:

You and your eligible dependents	Your covered employment terminates for reasons other than gross misconduct	18 months

You and your eligible dependents	You become ineligible for coverage due to a reduction in your employment hours (e.g., leave of absence)	18 months

You and your eligible dependents	You go on military leave	24 months

Your dependents	You die	36 months

Your spouse and stepchild(ren)	You legally separate, divorce or your marriage is civilly annulled	36 months

Your dependent child(ren)	Your dependent children no longer qualify as dependents	36 months

Your dependents	You terminate your employment or you reduce your work hours less than 18 months after the date of your Medicare (Part A or B or both) entitlement	36 months from the date of Medicare entitlement

If you marry, have a newborn child or have a child placed with you for adoption while you are covered under COBRA, you may enroll that spouse or dependent child for coverage for the balance of the COBRA continuation period, on the same terms available to active participants. The same rules about dependent status and qualifying changes in family status that apply to active participants will apply to you and/or your dependent(s).

FMLA leave. If you do not return to active employment after your FMLA leave of absence, you become eligible for COBRA continuation as a result of your termination of employment. For COBRA purposes, your employment is considered “terminated” at the end of the FMLA leave or the date that you give notice to your employer that you will not be returning to active employment, whichever happens first.

Multiple Qualifying Events. If your dependents qualify for COBRA coverage in more than one way, they may be eligible for a longer continuation coverage period up to 36 months from the date they first qualified. For example, if you terminate employment, you and your enrolled dependents may be eligible for 18 months of continued coverage. During this 18-month period, if your dependent child stops being eligible for dependent coverage under the Plan (a second Qualifying Event), your child may be eligible for an additional period of continued coverage.

The two periods combined cannot exceed a total of 36 months from the date of your termination (the first Qualifying Event). A second Qualifying Event may also occur if you become legally separated or divorced, or die.

Continued coverage for up to 29 months from the date of the initial event may be available to those who, during the first 60 days of continuation coverage, become totally disabled within the meaning of Title II or XVI of the Social Security Act. This additional 11 months is available to you and your eligible dependents if notice of disability is provided to the Fund within 60 days after the Social Security determination of disability is issued and before the 18-month continuation period runs out. The cost of the additional 11 months coverage will increase to 150% of the full cost of coverage.

To make sure you get all of the COBRA coverage you are entitled to, contact the Fund Office whenever something happens that makes you or your dependents eligible for COBRA coverage.

Notifying the Fund of a Qualifying Event. Under the law, in order to have a right to elect COBRA coverage, you or your dependent are responsible for notifying the Fund Office of your legal separation or divorce, a child losing dependent status under the Plan, or if you become disabled (or you are no longer disabled) as determined by the Social Security Administration. You (or your family member) must notify the Fund Office in writing of any of these events no later than 60 days after the event occurs or 60 days after the date coverage would have been lost under the Plan because of that event, whichever is later. Your notice must include the following information:

name(s) of the individual(s) interested in COBRA continuation, and the relationship to the participant
date of the Qualifying Event, and
type of Qualifying Event (see the table of Qualifying Events above).

When your employer must notify the Fund.

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Your employer is responsible for notifying the Fund of your death, termination of employment or reduction in hours of employment. Your employer must notify the Fund of one of these Qualifying Events within 30 days after the date of the loss of coverage. Once notified, the Fund will send you a COBRA notice within 30 days.

Making a COBRA election. Once the Fund is notified of your Qualifying Event, you will receive a COBRA notice and an election form. In order to elect COBRA, you or your dependent(s) must submit the COBRA election form to the Fund Office within 60 days after the date you would lose health coverage under the Fund or 60 days after the date of the COBRA notice, whichever is later.

Failure to give timely notice.

ALERT: 3/21/2012 NEW Click here for important benefit changes>>

If a participant or dependent does not give written notice within 60 days of the date of the Qualifying Event, or a contributing employer within 30 days of a Qualifying Event, and as a result, the Fund pays a claim for a person whose coverage terminated due to a Qualifying Event, then that person or the contributing employer, as applicable, must reimburse the Fund for any claims that should not have been paid. If the person fails to reimburse the Fund, all amounts due may be deducted from other benefits payable on behalf of that person, his or her dependents or the participant, if that person is a dependent.

Each of your eligible dependents has an independent election right for COBRA coverage. This means that each dependent can decide whether or not to continue coverage under COBRA.

Anyone who elects COBRA continuation coverage must promptly notify the Fund Office of address changes.

Paying for COBRA coverage. If you or your dependents elect to continue coverage, you or they must pay the full cost of the coverage elected. The Fund is permitted to charge you the full cost of coverage for active employees and families plus an additional 2% (and up to an additional 50% for the 11-month disability extension). The first payment is due no later than 45 days after the election to receive coverage (and it will cover the period from the date you would lose coverage until the date of payment). Thereafter, payments are due on the first of each month and are considered to be on time if they are made within 30 days of the due date. Costs may change from year to year. Contact the Fund Office for more information about the cost of your COBRA coverage.

If you fail to notify the Fund Office of your decision to elect COBRA continuation coverage or if you fail to make the required payment, your Plan coverage will end (and cannot be reinstated).

What COBRA coverage provides. COBRA generally offers the same coverage that is made available to similarly situated employees or family members, but Life/AD&PLC Insurance and Short-term Disability is not available. If, during the period of COBRA continuation coverage, the Plan’s benefits change for active employees, the same changes will apply to COBRA recipients.

When COBRA coverage ends. COBRA coverage ordinarily ends after the maximum coverage period shown in the chart above. It will stop before the end of the maximum period under any of the following circumstances:

A COBRA recipient fails to make the required COBRA contributions on time
A COBRA recipient becomes enrolled in Medicare (Part A, B or both) after the date of the COBRA election, or becomes covered under another group plan that does not have a pre-existing conditions clause that affects the COBRA recipient’s coverage.
Coverage has been extended for up to 29 months due to disability and there has been a final determination that the COBRA recipient is no longer disabled. The COBRA recipient must notify the Fund Office within 30 days of any such final determination.

If COBRA is terminated prior to the end of the original period, you will be notified.

Once your COBRA continuation coverage terminates for any reason, it cannot be reinstated.