If you are a covered employee or qualified beneficiary in California receiving federal COBRA continuation coverage, California extended "Cal-COBRA" coverage may apply to you.
After your federal COBRA continuation coverage period ends, under Cal-COBRA you may be eligible to receive up to 18 months of additional continuation coverage for a maximum total continuation coverage period of up to 36 months of combined federal COBRA and Cal-COBRA coverage. This 36-month period is measured from the original commencement date of your federal COBRA coverage. You must exhaust your federal COBRA continuation coverage in order to be eligible for Cal-COBRA coverage. Cal-COBRA coverage is not available to employees and qualified beneficiaries who receive 36 months of federal COBRA coverage.
Cal-COBRA coverage will terminate on the earliest of the following dates:
- The date the maximum period of coverage expires.
- The date your coverage under the group health plan ceases because a premium payment is not made on time.
- The date you become covered, after electing continuation coverage, under another group health plan that does not impose any pre-existing condition exclusion for a pre-existing condition of yours.
- The date you become entitled to Medicare benefits (under Part A, Part B or both) after electing continuation coverage.
- The date the employer no longer provides any group health plan.
- The date you move out of the provider's service area.
- The date you commit fraud or deception in the use of benefits.
Cal-COBRA applies to medical care plans, but not dental or vision care plans. Cal-COBRA coverage applies only to coverage under an insured plan or HMO, and not under a self-insured plan. You will receive additional information from the provider prior to your scheduled end-date for federal COBRA coverage.
If your former employer terminates its group contract with the insurer or HMO, the insurer or HMO must notify you of your right to convert to an individual policy. The replacement provider will also be required to cover any former employees (and other qualified beneficiaries) who have elected Extended Cal-COBRA coverage.
Generally, premiums for Cal-COBRA coverage is 110% of the applicable premium under the group health plan (150% for disability coverage).
Your Cal-COBRA continuation coverage will cost: [enter amount each qualified beneficiary will be required to pay for each available option per month of coverage].
Your periodic premium payments for continuation coverage should be sent to: [enter appropriate payment address].
InstructionsTo elect Cal-COBRA continuation coverage, complete this election form and return it to: [name and address]. This election form must be completed and returned by mail [or describe other means of submission and due date]. If mailed, it must be post-marked no later than [date]. If you don't submit a completed election form by the due date shown above, you'll lose your right to elect Cal-COBRA continuation coverage. Questions concerning your plan or your COBRA continuation coverage rights should be addressed to: [name of plan and name (or position), address and phone number of party from whom information about the plan and Cal-COBRA continuation coverage can be obtained on request.] I/(We) elect Cal-COBRA continuation coverage in the [name of plan] listed below: |
Employee | Eligible Dependent Relationship to Employee |
Eligible Dependent [Add additional fields for more dependents, if necessary] | Eligible Dependent |
_____________________________________ ____________________________
Signature Date
______________________________________ _____________________________
Print name Relationship to individual(s) listed above
______________________________________________________________________
Print address
_____________________________________
Telephone number
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