More information about continuation coverage and your rights under the Plan is available in your summary plan description or from the Plan Administrator.

If you have any questions concerning the information in this notice, your rights to coverage, or if you want a copy of your summary plan description, you should contact the Trust Fund Office at P.O. Box 5628, El Monte, California 91734, (626) 279-3054.

For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, visit the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) website at www.dol.gov/ebsa or call their toll-free number at 1-866-444-3272.  For more information about health insurance options available through the Health Insurance Marketplace, and to locate an assister in your area who you can talk to about the different options, visit www.HealthCare.gov.

Claims and appeals procedures for benefits shall apply in accordance with the Plan’s rules as described in the Plan’s summary plan description.  If a claim is denied, you will have the right to appeal.  Procedures for filing claims or filing an appeal are described in the summary plan description.

Summary of what you need to do if you receive this notice along with a COBRA Continuation Coverage Election Form:

• Review this letter and all materials enclosed.
• Complete and sign the attached “COBRA Continuation Coverage Election Form.” The “Continuation Coverage Election Notice (COBRA)” should include the qualifying event which caused the termination of your health coverage plan and other information specifically for you and other qualified beneficiaries under the Plan.

Return the COBRA Continuation Coverage Election Form to the Trust Fund Office by the date specified on the Election Form.

Life insurance or accidental death and dismemberment benefits may not be continued under COBRA.  To convert your life insurance and accidental death and dismemberment coverage to an individual policy, you must contact the Member Services Department of your Life Insurance Carrier within 31 days upon the expiration of your group coverage.

Some or all of the medical, dental, vision, or prescription coverage plans may provide you with the option of converting your group health coverage to an individual conversion policy whether you do not elect COBRA or if you exhaust your health benefits under COBRA.  If you qualify for conversion coverage and would like to convert your coverage, you must do so within 31 days of the end of your Plan coverage.  Please contact the Member Services Department of your HMO directly and immediately upon the expiration of your Plan coverage for more information about the availability of a conversion policy.

If at the time of a qualifying event your medical and prescription drug coverage is provided through a health maintenance organization (HMO), your coverage which would otherwise end under federal law may be required to be extended by the HMO to a total of 36 months under California law. You must contact the HMO directly and immediately upon the expiration of your federal COBRA coverage to obtain eligibility information for Cal-COBRA and how to apply for it.

If you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be able to enroll your dependents.

To be entitled to special enrollment because of a new spouse or dependent, you must either be covered or eligible to be covered under your plan.  You must complete and submit an enrollment form to the Trust Fund Office, along with any necessary official documentation, within 31 days from the date of your marriage or the date you acquired a new dependent.  In the case of a newborn or adopted child that is added to COBRA coverage, the first 60 days continuation coverage is measured from the date of birth or placement for adoption.

If a COBRA payment is not received within 30 days of the beginning of the covered month or if you fail to make your COBRA payment, your continuation coverage under COBRA will terminate at the end of the last month for which you paid for coverage and you will be responsible for reimbursing the Plan for any benefits received in error.

First payment for continuation coverage

If you elect continuation coverage, you do not have to send any payment with the Election Form. However, you must make your first payment for continuation coverage not later than 45 days after the date of your election. (This is the date the Election Notice is post-marked, if mailed.) If you do not make your first payment for continuation coverage in full not later than 45 days after the date of your election, you will lose all continuation coverage rights under the Plan. You are responsible for making sure that the amount of your first payment is correct. You may contact the Trust Fund Office to confirm the correct amount of your first payment.

Periodic payments for continuation coverage

After you make your first payment for continuation coverage, you will be required to make periodic payments for each subsequent coverage period. Monthly premiums for successive periods of coverage are due by the 20th of the preceding month for the month that you seek coverage so that eligibility is accurately reflected in the Trust records. Although periodic payments are due on the 20th of the preceding month, you will be given a grace period of 40 days or within 30 days of the beginning of the covered month to make such periodic payment. Payment is considered made on the date it is received by the plan. Your continuation coverage will be provided for each month as long as the payment for that month is made before the end of that month.

However, if you pay a periodic payment later than the first day of the covered month, but before the end of that month, your coverage under the Plan will be suspended as of the first day of the covered month and then retroactively reinstated (going back to the first day of the covered month) when the periodic payment is received. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated.

Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. The amount a qualified beneficiary may be required to pay may not exceed 102 percent (or, in the case of an extension of continuation coverage due to a disability, 150 percent) of the cost to the group health plan (including both employer and employee contributions) for coverage of a similarly situated plan participant or beneficiary who is not receiving continuation coverage. The required payment for each continuation coverage period for each option is described in this notice.

To elect continuation coverage, you must complete the Election Form and furnish it according to the directions on the form. Each qualified beneficiary has a separate right to elect continuation coverage. For example, the employee’s spouse may elect continuation coverage even if the employee does not. Continuation coverage may be elected for only one, several, or for all dependent children who are qualified beneficiaries. A parent may elect to continue coverage on behalf of any dependent children. The employee or the employee’s spouse can elect continuation coverage on behalf of all of the qualified beneficiaries.

In considering whether to elect continuation coverage, you should take into account that you have special enrollment rights under federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse’s employer) within 30 days after your group health coverage ends because of the qualifying event listed above. You will also have the same special enrollment right at the end of continuation coverage if you get continuation coverage for the maximum time available to you.

Please be aware that the Plan does not provide coverage until you have both elected COBRA and paid the applicable premium due. If you elect COBRA and pay the premium timely, your coverage will be reinstated retroactively to the first day of your COBRA period.