Teamsters Local 805 Welfare Fund

SUMMARY PLAN DESCRIPTION -

COBRA CONTINUATION OF HEALTH COVERAGE (FOR MEDICAL, DENTAL, VISION AND PRESCRIPTION DRUG BENEFITS ONLY)

This section contains important information about COBRA continuation coverage, which is a temporary extension of group health coverage (i.e., medical, dental, vision and prescription drug benefits) under the Plan under certain circumstances in the event that you or your family members lose your coverage. The right to elect COBRA coverage was created by federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended (COBRA).

This notice generally explains 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. This notice gives only a summary of your continuation coverage rights under the Plan. For more information about your rights and obligations under federal law, you should review the entire Summary Plan Description.
COBRA continuation coverage is administered by the Fund Office. You can contact the Fund Office at the address and telephone number listed in this booklet.

i. COBRA Continuation Coverage – In General
COBRA continuation coverage is a continuation of your health coverage under the Plan when coverage would otherwise end because of an event known as a “qualifying event.” Specific qualifying events are listed below. After a qualifying event, COBRA continuation coverage is offered to each person who is a “qualified beneficiary.” You, your spouse and your dependent children could become qualified beneficiaries if coverage under the Fund is lost because of a 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 coverage under the Plan because one of the following qualifying events happens:

• Your work hours are reduced so that you are no longer eligible for coverage under the Plan’s benefit program.
• Your employment ends for any reason other than your gross misconduct.

If you are the spouse 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’s work hours are reduced so that you are no longer eligible for coverage under the Plan’s benefit program;
• Your spouse’s employment ends for any reason other than his or her gross misconduct;
• Your spouse dies, 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’s work hours are reduced,
• The parent-Employee’s employment ends for any reason other than his or her gross misconduct,
• The parent-Employee dies,
• The parents become divorced or legally separated, or
• The child’s eligibility for coverage under the Plan ends because he or she no longer qualifies as a “Dependent child.”

Children who are born to or placed for adoption with a covered Employee during the period of the Employee’s continuation coverage also are qualified beneficiaries entitled to COBRA continuation coverage. Once the newborn or adopted child is enrolled in continuation coverage pursuant to the Plan’s rules, the child will be treated like all other qualified beneficiaries with respect to the same qualifying event. The maximum coverage period for such a child is measured from the same date as for other qualified beneficiaries with respect to the same qualifying event (and not from the date of the child’s birth or adoption).

ii. Notice of COBRA Qualifying Event
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Fund Office has been notified that a qualifying event has occurred. When the qualifying event is the end of employment or reduction in work hours, or the death of the employee, your employer must notify the Fund Office of the qualifying event. You should also inform the Fund Office promptly in writing upon the occurrence of any of these events so as to avoid confusion as to the status of your health coverage.

You Must Give Notice of Some Qualifying Events

For the other qualifying events (i.e., divorce or legal separation of the employee and spouse, or a Dependent child losing eligibility for coverage as a Dependent child), you (or your family member) must notify the Fund Office within 60 days after the date of the qualifying event. You must provide this notice in writing and send it to the Plan Administrator at the Fund Office, Roderick Gorham, Local 805 Welfare Fund, 44-61 11th St., 3rd Floor, Long Island City, NY 11101. Your written notice must include: (i) the name of the employee, (ii) the name(s) of the qualified beneficiary(ies) who will lose coverage due to the event, (iii) the type of qualifying event, and (iv) the date on which the event occurred.

The Employee or family member (or any representative acting on behalf of either) can provide notice on behalf of himself as well as other family members affected by the qualifying event.

iii. How is COBRA Coverage Provided?
Once the Fund Office 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.

iv. How Long Does COBRA Coverage Last?
COBRA continuation coverage is a temporary continuation of your health coverage under the Fund. When the qualifying event is the death of the Employee, your divorce or legal separation, or a Dependent child 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 in the Employee’s work hours, COBRA continuation coverage generally lasts for only a total of 18 months (except as described below, when an 18-month period of COBRA coverage can be extended). However, if the qualifying event is the end of employment or reduced hours of employment, and the Employee became entitled to Medicare benefits less than 18 months before the qualifying event (termination or reduced hours), COBRA continuation coverage for qualified beneficiaries other than the Employee lasts until 36 months after the date of the Medicare entitlement. For example, if a covered Employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which would be 28 months of continuation coverage after the date of the qualifying event (36 months minus 8 months).

As noted, there are two ways an 18-month period of COBRA continuation coverage can be extended, as follows:

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 (SSA) to be disabled and you notify the Fund Office 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 your COBRA continuation coverage and must last at least until the end of the 18-month period of continuation coverage. Written notice of the SSA Disability determination (along with a copy of the SSA Award) must be sent to the Plan Administrator at the Fund Office, Roderick Gorham, Local 805 Welfare Fund, 44-61 11th St., 3rd Floor, Long Island City, NY 11101, within 60 days of the latest of (i) the date of the SSA determination, (ii) the date of your initial qualifying event, (iii) the date on which you lost coverage under the Fund due to the initial qualifying event, or (iv) the date on which you are informed of these procedures for providing this notice. Your written notice must include: (i) the covered employee’s name, (ii) the qualified beneficiary’s(ies’) name(s), (iii) the name of the person who has been determined to be disabled by SSA, and (iv) the date of the determination. Notice from one individual will satisfy the notice requirement for all related qualified beneficiaries affected by the same qualifying event.

If the SSA determines that the individual is no longer disabled, this extended period of COBRA coverage will end as of the last day of the month that begins more than 30 days after the SSA has determined that the individual is no longer disabled. The disabled individual or a family member is required to notify the Fund Office within 30 days of any such determination. In addition, the extended coverage may also be terminated for any of the reasons set forth on page 29.

Second Qualifying Event Extension of 18-month Period of Continuation Coverage. If your family member experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse and Dependent children 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 Fund Office. This extension may be available to the spouse and Dependent children receiving continuation coverage if the Employee or former Employee dies, gets divorced or legally separated, or if the Dependent child stops being eligible under the Plan as a Dependent child, but only if that event would have caused the spouse or Dependent child to lose coverage under the Fund had the first qualifying event not occurred.

In all of these cases, you (or your family member) must make sure that the Fund Office is notified in writing of the second qualifying event within 60 days of the second qualifying event. This notice must be sent to the Plan Administrator at the Fund Office, Roderick Gorham, Local 805 Welfare Fund, 44-61 11th St., 3rd Floor, Long Island City, NY 11101. Your written notice must identify: (i) the Employee, (ii) the second qualifying event, (iii) the date on which the event occurred, and (iv) the names of the covered individuals whose coverage under the Plan will be lost due to the event. In addition, you must include with the notice a copy of the Employee’s death certificate, divorce decree or proof of legal separation, or a copy of the child’s birth certificate or other proof of age, as applicable depending on the qualifying event. The Employee or family member can provide notice on behalf of themselves as well as other family members affected by the qualifying event.

v. Electing COBRA Coverage
Qualified Beneficiaries have 60 days from the later of (i) the date of the loss of coverage because of the qualifying event, or (ii) the date they are furnished with a COBRA Election Notice, to elect COBRA continuation coverage. Election Forms must be post marked within that 60-day period and must be received by the Fund Office. For each qualified beneficiary who timely elects and pays for COBRA continuation coverage, coverage will begin on the date that coverage under the Plan would otherwise have been lost due to the qualifying event. If you timely elect (and pay for) COBRA continuation coverage, you are entitled to be provided with coverage that is identical to the coverage being provided under the Plan to similarly situated employees (or their family members). If you do not timely elect (and pay for) COBRA continuation coverage, your health coverage under the Plan will end.

Special Second Election Period for TAA Eligible Individuals

The Trade Act of 2002 created a new tax credit for certain individuals who become eligible for trade adjustment assistance (“TAA Eligible Individuals”). Under the new tax provisions, TAA Eligible Individuals can either take a tax credit or get advance payment of 65% of premiums paid for qualified health insurance, including COBRA continuation coverage.

TAA Eligible Individuals who did not previously elect continuation coverage during the original 60-day COBRA election period that applied to the TAA-related loss of coverage may elect continuation coverage during a second 60-day election period. This second 60-day election period begins on the first day of the month in which he or she is determined to be a TAA Eligible Individual, provided that such election may not be made later than 6 months after the date of the TAA-related loss of coverage. TAA Eligible Individuals may elect continuation coverage for themselves and their eligible family members. Any continuation coverage elected will begin with the first day of the second 60-day election period, and not on the date the coverage originally was lost. However, the time between the loss of coverage and the start of the second election period will not be counted for purposes of determining whether the individual has a 63-day break in coverage under the Health Insurance Portability and Accountability Act (HIPAA).

If you have questions about these new special provisions or you are not sure whether you are a TAA Eligible Individual, contact the Health Coverage Tax Credit Customer Contact Center toll-free at 1-866-628-4282. TTD/TTY callers may call toll-free at 1-866-626-4282. More information about the Trade Act is also available at www.doleta.gov/tradeact.

vi. Paying for COBRA Coverage
Individuals who continue coverage under COBRA must pay up to 102% of the Plan’s cost of coverage, except in cases of extended continuation coverage due to disability, in which case you will be required to pay 150% of the cost of coverage. The Fund Office will notify you of the cost of the coverage at the time you receive your notice of entitlement to COBRA coverage, and will also notify you of any changes in the monthly COBRA premium amount. There will be a grace period of 45 days to pay the first premium payment, which must include the premiums due for all months starting with the date your active coverage ended and continuing through your date of payment. If this payment is not made within 45 days of the date of your COBRA election, you (and your family members) will not be entitled to COBRA continuation coverage.

After the initial premium payment, monthly premium payments are due on the first day of each month and there will be a grace period of 30 days each month to make these payments. If a monthly payment is not made by the end of the applicable grace period, your (and your family’s) COBRA coverage will terminate retroactive to the last date for which you timely paid for coverage. Premium payments must be post-marked within the applicable grace period and must be received by the Fund Office.

vii. Early Termination of Continuation Coverage
The law provides that continuation coverage may be cut short prior to the end of the applicable 18, 29 or 36 month period for any of the following reasons:

• The premium for continuation coverage is not timely paid (within the applicable grace period).
• The group health coverage provided to you is terminated (and the plan sponsor is not required by COBRA to provide you with other group health coverage that it maintains, if any).
• The individual first becomes, after the date of the COBRA election, covered under another group health plan (as an employee or otherwise) that does not contain any preexisting condition exclusion or limitation applicable to the individual.
• The individual becomes entitled to Medicare (under Part A, Part B, or both) after electing COBRA coverage.
• Coverage has been extended for up to 29 months due to disability and there has been a final determination that the individual is no longer disabled. In this case, coverage will end as of the month that begins more than 30 days after the date of such final determination. You are required to notify the Plan Administrator in writing within 30 days of any such final determination.
• If you fail to follow the Plan’s policies and procedures and take actions that would result in termination of an active employee’s coverage for cause. (For example, if you submit false claims to the Plan.)
• When the Employer that employed you prior to the qualifying event has stopped contributing to the Plan and the Employer makes group health coverage available to (or starts contributing to another multiemployer plan for) a class of the Employer’s employees who were formerly covered by the Plan.

viii. If You Have Questions
The Fund Office is responsible for administering COBRA coverage. For additional information regarding COBRA continuation coverage or to obtain COBRA continuation election forms, contact the Fund Office of the Teamsters Local 805 Welfare Fund, 44-61 11th Street, Third Floor, Long Island City, New York 11101. The telephone number is (718) 609 6401.

You may also obtain COBRA continuation coverage information by contacting the nearest Regional or District Office of the U. S. Department of Labor’s Employee Benefits Security Administration (EBSA) or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, NW, Washington, DC 20210.

Addresses and telephone numbers of Regional and District EBSA Offices are available through EBSA’s website at www.dol.gov/ebsa.

F. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT

i. Special Enrollment Rights
Individuals who are otherwise eligible, but had declined health coverage because they had other group health plan or health insurance coverage, must be permitted to enroll in the plan (regardless of any late enrollment provisions) upon “loss of eligibility” for the other coverage or if employer Contributions toward the other coverage cease. The plan may require that an employee's decision to decline on behalf of themselves or their dependents be made in writing, and may later deny special enrollment if the employee does not comply, provided that the employee was notified of both the requirement and the consequences of non-compliance. Loss of eligibility includes loss of coverage due to legal separation, divorce, voluntary or involuntary termination of employment, reduction in hours, children’s aging out of coverage, moving out of an HMO service area, exhaustion of COBRA coverage, or exceeding the lifetime benefit limit, regardless of whether the individual who loses eligibility is eligible for or elect COBRA. It does not include loss of coverage due to a failure of the individual to pay premiums on a timely basis or termination of coverage for cause. Special enrollment rights are also triggered when employer Contributions toward an individual’s other coverage cease, regardless of whether the individual is still eligible for coverage under the other plan.

Group health plans are required to offer special enrollment to otherwise eligible employees, spouses, and any new dependents upon marriage, birth, adoption, or placement for adoption. An employee who is otherwise eligible, but not enrolled for coverage, can enroll (and can also enroll a spouse and any new dependents, if they are otherwise eligible under the plan) when any of these events occur.

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself or your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing towards your or your dependents' other coverage). However, you must request enrollment within 30 days after your or your dependents' other coverage ends (or after the employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

To request special enrollment or obtain more information, contact the Plan Administrator, Roderick Gorham, Local 805 Welfare Fund, 44-61 11th St., 3rd Floor, Long Island City, NY 11101.

ii. Health Certificates – Certificate of Creditable Coverage
When your Fund coverage ends, you and/or your dependents are entitled by law to, and will be provided with, a "Certificate of Creditable Coverage." Certificates of Creditable Coverage indicate the period of time you and/or your dependents were covered under the Fund (including COBRA coverage), as well as certain additional information required by law. The Certificate of Creditable Coverage may be necessary if you and/or your dependents become eligible for coverage under another group health plan, or if you buy a health insurance policy within 63 days after your coverage under this Fund ends (including COBRA coverage). The Certificate of Creditable Coverage is necessary because it may reduce any exclusion periods for pre-existing conditions that may apply to you and/or your dependents under the new group health plan or health insurance policy.

The Certificate of Creditable Coverage will be provided to you:

• on your request, within 24 months after your Fund coverage ends
• when you are entitled to elect COBRA
• when your coverage terminates, even if you are not entitled to COBRA
• when your COBRA coverage ends.

You should retain these Certificates of Creditable Coverage as proof of prior coverage for your new health plan. For further information, call the Fund Office.