COBRA Form: Notice of Rights to Continue Coverage

EMPLOYEE'S NAME

NOTICE OF RIGHTS TO CONTINUE COVERAGE

On April 7, 1986, a federal law was enacted [Public Law 99-272, Title X] requiring that most employers sponsoring group health plans offer employees and their families the opportunity for a temporary extension of health coverage (called "continuation coverage") at group rates in certain instances where coverage under the plan would otherwise end. This notice is intended to inform you, in a summary fashion, of your rights and obligations under the continuation coverage provisions of the law. [BOTH YOU AND YOUR SPOUSE SHOULD TAKE THE TIME TO READ THIS NOTICE CAREFULLY.]

If you are a participant in the State's Group Benefits Plan and are covered by a Blue Cross & Blue Shield, Presbyterian Health Plan, Cigna, Delta Dental, or EyeMed, you have the right to choose this continuation coverage if:

• 1) Reduction in Work Hours
• 2) Termination of Employment, except for gross misconduct
• 3) Death of Employee
• 4) Dependent Ceasing to be Eligible
• 5) Legal Separation or Divorce
• 6) Social Security Disability
• 7) Voluntary Termination
• 8) Retirement

Under the law, the employee or a family member has the responsibility to inform the Human Resources Office, who will inform the Third Party Administrator, Erisa, if there is a divorce, legal separation, or a child losing dependent status under the laws of the State of New Mexico, within 31 days of the date of the event or the date in which coverage would end under the plan because of the event, whichever is later. The HR Representative has the responsibility to notify the Erisa of any of the COBRA qualifying events.

Erisa will send you a COBRA enrollment packet, including notification of your right to choose continuation of coverage. Under the law, you have 60 days from the date you lose coverage to elect COBRA.

If you choose continuation of coverage, it must be identical to the coverage you had as of the qualifying event. Please call Erisa's COBRA Unit for details on length of coverage.

The law provides that your continuation coverage may be terminated for any of the following reasons:

1. The State of New Mexico no longer provides group health coverage to any of its employees;
2. Employer group is no longer a participant in the State's Group Benefits Plan;
3. The premium for your contribution coverage is not paid on time;
4. You become covered by another group plan, unless the plan contains any exclusions or limitations;
5. You become entitled to Medicare;
6. Your classification of disability ends.

Premium payments are due upon receipt of the monthly invoice. There is a grace period of 45 days for payment of the monthly premium. Any attempt to make payment after the expiration of the 45-day grace period will not be accepted. Failure to make premium payment will result in termination of coverage.

This law applies to medical, dental and vision coverage beginning on July 1, 2000 under Section 10002(d) of COBRA.

If you have any questions about the law please contact Erisa COBRA Unit at 1-855-618-1800.