ESHCA, Inc.'s Employer Member Health & Welfare Plans are self insured. We use MVP Health Care as our third party administrator. The Summary Plan Description (SPD) that you receive from ESHCA when you become eligible for health coverage contains a full description of the benefits.
You qualify for health insurance benefits on the first day of the month following completion of 800 hours of employment during the immediately preceding 12 month period with one or more Employer Members. Please contact your employer to discuss your eligibility.
Continuation of Health Benefit
Health insurance coverage shall continue during periods in which you are unemployed because of lack of work until the earlier of the last day of the month following six (6) months of unemployment or the May 1st of the calendar year immediately following your layoff due to lack of work. Your coverage will continue beyond the above stated period of time if you return to work for any Employer Member of the Empire State Highway Contractors Association, Inc. before the first of May
Termination of Health Benefits
Your health and life insurance coverage will terminate if:
You are unemployed on May 1st immediately following your last termination for lack of work;
You are unemployed for more than six (6) months;
You voluntarily terminate employment with all Employer Members;
You are terminated by the Employer for cause; or
You become employed by an employer who is not an Employer Member.
Reinstatement of Health Benefit
If your coverage terminates on May 1st you will be eligible for reinstatement of coverage on the first of the month following your return to work if your period of unemployment is less than six (6) months. You will be eligible for restatement at the rate of one (1) month of coverage for each 100 hours worked until you have worked a minimum of 800 hours in that current calendar year.
Certificates of Coverage
Certificates of coverage are written documents provided by this Plan to show the type of health coverage a Participant has and how long the coverage lasted. The Plan will automatically provide a certificate to you after you lose health coverage under the Plan, become entitled to elect COBRA continuation coverage, when COBRA continuation coverage ceases, if you request a certificate before losing coverage, or if you request it up to 24 months after coverage terminates. The Plan Administrator can give you details about how to obtain certificates from prior plans and the alternative types of proof that you can use to show your creditable coverage.
Continuation of Coverage After Termination - Cobra Continuation
Under a Federal law called the Consolidated Omnibus Budget Reconciliation Act (COBRA), your Employer is required to offer to covered employees and covered family members the opportunity to elect temporary health care continuation coverage at group rates when coverage under the Plan would otherwise end due to certain qualifying events ( e.g. , you lose or leave your job). Continuation coverage lasts only for a limited period of time and you have to pay for it. This section is intended to inform you (and any covered spouse and covered dependents) in a summary fashion of your rights and obligations under COBRA.
A. Eligibility for Continuation Coverage - Qualifying Events
(a) For covered employees - If you are an employee covered under the Plan, you may be entitled to elect continuation coverage if you lose your group health plan coverage because of (a) termination of your employment (for reasons other than gross misconduct) or a reduction of your hours of employment; or (b) if you are a retired covered employee and you lose coverage due to the bankruptcy of your Employer.
(b) For covered spouses - If you are the spouse of a covered employee and are covered under the Plan, you may be entitled to elect continuation coverage if you lose group health coverage for any of the following qualifying events:
Termination of your spouse's employment (for reasons other than gross misconduct) or a reduction in your spouse's hours of employment;
Death of your spouse;
Divorce or legal separation from your spouse;
Your spouse becomes entitled to Medicare (Part A or B); or
The Employer starts bankruptcy proceedings, and your spouse is a retired employee.
(c) For covered dependent children - If you are the dependent child of a covered employee and are covered under the Plan, you may be entitled to elect continuation coverage if you lose group health coverage for any of the following qualifying events:
Termination of a parent's employment with the Employer (for reasons other than gross misconduct) or a reduction in a parent's hours of employment with the Employer;
Death of the parent employed by the Employer;
Parents' divorce or legal separation;
A parent employed by the Employer becomes entitled to Medicare (Part A or B);
You cease to be a "dependent child" under the Plan; or
The Employer starts bankruptcy proceedings, and your parent is a retired employee.
NOTE: A child born or placed for adoption with a covered employee during the continuation coverage period is a covered dependent entitled to elect COBRA coverage. The coverage period will be determined according to the date of the qualifying event that gave rise to the covered employee's COBRA coverage. You must notify the Plan Administrator within 31 days of the birth or adoption to add the child to the COBRA coverage.
B. COBRA Eligibility
You do not have to show that you are insurable to elect continuation coverage. However, you must be covered under the health insurance portion of the Plan at the time of a qualifying event in order to be eligible to elect continuation coverage (except for children born or placed for adoption during the continuation coverage period). The Employer reserves the right to verify eligibility and terminate continuation coverage retroactively if you are determined to be ineligible or if there has been a material misrepresentation of the facts. Under the law, covered employees, covered spouses, and covered dependent children are known as "qualified beneficiaries".
C. COBRA Election Period
Once the Plan Administrator is notified that a qualifying event has occurred, the Plan Administrator will notify qualified beneficiaries of their right to elect continuation coverage. Each qualified beneficiary has an independent election right and will have 60 days from the later of the date coverage is lost under the Plan or from the date of notification to elect continuation coverage. An election may be made on behalf of a qualified beneficiary by a third party. If a qualified beneficiary does not elect continuation coverage within the 60-day period, all rights to continuation coverage will end.
If a qualified beneficiary elects to continue coverage and pays the applicable premium, the Employer is required to provide such individual with coverage that is identical to the coverage provided under the Plan to similarly situated active employees, including the opportunity to choose among options during an open enrollment period. If coverage is changed or modified for similarly situated active employees, then continuation coverage may be similarly changed and/or modified.
D. Length of Continuation Coverage.
The law requires that you be afforded the opportunity to maintain continuation coverage for 36 months, unless you lost group health coverage because of a termination of employment or a reduction in hours. In that case, the required coverage period is 18 months.
The 18 months may be extended to 29 months if you receive a determination from the Social Security Administration stating that you were disabled at any time during the first 60 days of COBRA coverage. This 11-month extension for disability will be available to each individual in your family who is a qualified beneficiary and is receiving continuation coverage as a result of a termination of employment or a reduction in hours, if any qualified beneficiary is disabled in the first 60 days of continuation coverage.
If a second qualifying event (such as a death, divorce, legal separation or Medicare entitlement) occurs within the 18-month or 29-month coverage period, the continuation coverage period is extended up to a maximum of 36 months from the date of the termination of employment or reduction in hours
E. Extended period for retirees of bankrupt employer.
If the qualifying event causing the loss of coverage was the Employer's bankruptcy, each covered retired employee will have the opportunity to receive COBRA coverage until the death of the covered retired employee. Covered spouses, surviving spouses and dependents of the covered retired employee will have the opportunity to elect continuation coverage for a period that will terminate 36 months following the death of the retired employee or upon the death of the qualified beneficiary, whichever is earlier.
F. Notification Requirements.
Qualified Beneficiaries have the responsibility to inform the Employer of a divorce, legal separation, or a child losing "dependent status" under the Plan. This notification must be made within 60 days from the later of: (i) the date of the qualifying event or (ii) the date that coverage would be lost under the terms of the insurance contract because of the event. Failure to provide timely notice will result in the loss of continuation coverage.
With respect to the disability extension described above, qualified beneficiaries must notify the Plan Administrator within 60 days of the determination by the Social Security Administration and before the expiration of the original 18-month period. You must also notify the Plan Administrator within 30 days of any final determination that the individual is no longer disabled. If this notification is not made in a timely manner, then your rights to continuation coverage may be forfeited .
Note: In the event of an employee's death, termination of employment, reduction in hours or entitlement to Medicare, the Employer will inform the qualified beneficiary of his or her right to choose continuation coverage.
G. COBRA Premiums.
A qualified beneficiary must pay the applicable premium and the Employer may charge a two percent (2%) administration surcharge for administration. The premiums may be adjusted in the future if the applicable premium amount changes. Initial payment must be forwarded to the Employer within 60 days after termination of coverage or, if later, the date you are notified of your right to COBRA coverage. A grace period of 45 days after your initial election is provided if the initial payment is not received with your election. All subsequent payments must be made on a monthly basis, no later than the first day of each month. There is a grace period of 30 days for the regularly scheduled monthly premiums.
If the continuation period is extended beyond 18 months due to a Social Security Administration determination of disability, the Employer may charge up to 150% of the applicable premium during the extended period.
H. Termination of Continuation Coverage.
The law allows COBRA continuation coverage that has been elected and paid for to be terminated prior to the maximum continuation period for any of the following reasons:
The maximum COBRA coverage period ( i.e. , 18, 29 or 36 months) expires.
Any required premium is not paid in a timely fashion.
The Employer ceases to provide group health coverage to any of its employees.
A qualified beneficiary becomes covered, after the date on which COBRA was elected, under another group health plan that does not contain any exclusion or limitation with respect to any preexisting condition of such beneficiary (other than an exclusion or limitation which does not apply to, or has been satisfied under HIPAA).
A qualified beneficiary first becomes entitled to Medicare after the date of the COBRA election.
A qualified beneficiary wishes to cancel continuation coverage.
In the case of a qualified beneficiary who has extended coverage due to a disability, coverage may end on the later of (i) 29 months after the date of the qualifying event or the first day of the month that is more than 30 days after the date of a final determination from the Social Security Administration that the disabled qualified beneficiary is no longer disabled; or (ii) the end of the maximum coverage period that applies to the qualified beneficiary without regard to the disability extension.
For cause, such as fraudulent claim submission, on the same basis that coverage could terminate for similarly situated active employees.
I. Conversion Rights After COBRA.
At the end of the COBRA coverage period, a qualified beneficiary must be given the option to enroll in an individual conversion health plan provided under the Plan within 180 days, if such plan is available. You may request conversion forms directly from your carrier.