2021 Benefits Overview

The right to COBRA Continuation Coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA Continuation Coverage can become available to you when you would otherwise lose your group health coverage. It can also become available to members of your family who are covered under the plan when they would otherwise lose their group health coverage.

COBRA Continuation Coverage is just what the name implies, simply a continuation of the coverage you had as an employee, spouse or covered dependent. The plan benefits are exactly the same as what you enjoyed as a regular covered member.

The U.S. Department of Labor, Employee Benefits Security Administration (EBSA), developed a publication entitled An Employee’s Guide to Health Benefits Under COBRA.

Your Member Handbook and the Summary of Material Modifications are documents that have important information about COBRA. You can find both of these documents in the medical section of the Samaritan Choice benefits page.

Please contact Samaritan Health Plans Customer Service for any questions you have about COBRA. You can reach them Monday through Friday, from 8 a.m. to 8 p.m. by calling 541-768-4550, 800-832-4580, or TTY 800-735-2900, or in person, Monday through Friday, from 8 a.m. to 5 p.m. at Samaritan Health Plans, 2300 NW Walnut Blvd., Corvallis, OR 97330.

Qualified beneficiaries after there has been a qualifying event.

A person who was covered by a group health plan on the day before a qualifying event occurred. This person must either be an employee, the employee’s spouse or former spouse, the employee’s dependent child, or other legal dependents as outlined in the Member Handbook.

Qualifying events are specific situations that happen to a covered employee, spouse and/or dependent that result in a loss of group health coverage. Qualifying events include: 

• Termination or reduction in hours of covered employee for reasons other than fraud
• Death of a covered employee
• A covered employee becoming entitled to Medicare
• Divorce or legal separation of a covered employee and spouse
• A child’s loss of dependent status under the plan

Qualifying events occur while the employee/covered dependents are still receiving group health coverage. Second qualifying events occur after the employee/qualified beneficiaries are receiving COBRA Continuation Coverage.

It is the responsibility of the employee, spouse and/or dependent to report a divorce, legal separation and a child’s loss of dependent status to your local Samaritan Health Services Human Resources Department within their required time frame. If these events occur while on COBRA Continuation Coverage, report them to Samaritan Health Plans within a 60-day time frame. Termination/reduction in hours, death, or entitlement to Medicare must be reported to the plan administrator by the employer within 30 days of the event.

Fill out the COBRA Continuation Coverage Election Form and mail or hand-deliver it to Samaritan Health Plans within the required timeline. Follow the specific instructions on the form. This form should be used for all qualified beneficiaries electing COBRA Continuation Coverage.

Mail to:  
Samaritan Health Plans
PO Box M
Corvallis, OR 97339

Hand-deliver to:
Samaritan Health Plans
2300 NW Walnut Blvd.
Corvallis, OR 97330

No. Each qualified beneficiary has an independent right to elect COBRA Continuation Coverage. For example, a family that had all the same coverage, medical/pharmacy and dental/vision, before the qualifying event, may make independent election decisions when they elect COBRA. Some individuals may want to continue both medical/pharmacy and dental/vision, while other individuals may only want medical/pharmacy, or not want COBRA coverage at all. The qualified beneficiaries can select from the plans they were covered on at the time of the qualifying event. Premiums are based on the elections chosen.

Once you submit your election form you are considered benefit eligible retroactive to your loss of coverage date. If you do not make your initial payment at the time you elect, you will not be payment eligible and claims will be denied. When you make the full initial premium payment within the required 45 days after you elect, you will be both benefit and payment eligible and claims during that election period will be reprocessed. Providers verifying your eligibility during this period will be told the status of your election and premium payment.

You may need to pay for the prescription. Once you have paid the initial premium payment and become payment eligible, then submit a reimbursement request to Samaritan Health Plans which will be reviewed against your pharmacy benefit. Reimbursement forms are located under the Member Forms on the Samaritan Choice Benefits page.

When you have COBRA Continuation Coverage, the plan benefits are the same as what you had as a regular covered member. When you elect COBRA, you may select from the coverage plans you had before the event. The same plan options available to plan members not on COBRA are available to COBRA members.

As long as you had dental coverage the day before the qualifying event, you may choose to continue these benefits. You may choose the same plan you had at the time you lost coverage.

Coverage begins the first day after your group health coverage ends. Your group health coverage will ordinarily end on the last day of the month, and your COBRA Continuation Coverage will begin the next day. There cannot be a gap in coverage and you cannot skip months. COBRA coverage will end when your benefit period expires, or if you are terminated early. (See question, Why would my COBRA Continuation Coverage be terminated early?)

The type of qualifying event determines who the qualified beneficiaries are for that event and the period of time the plan must offer continuation coverage. The chart below helps explain who qualifies for what length of coverage by qualifying event:

	Maximum coverage period	Qualified beneficiaries (Only members covered by the plan the day before the event occurred or a child born to or placed for adoption with a covered employee during continuation coverage)
Covered employee’s termination of employment	18 months	Employee, spouse, dependents
Covered employee’s reduction in work hours (for any reason) below those required to maintain normal coverage	18 months	Employee, spouse, dependents
Covered employee’s divorce or legal separation	36 months	Spouse, dependents
Covered employee’s death	36 months	Spouse, dependents
Covered employee’s entitlement to Medicare benefits	Up to 36 months	Spouse, dependents
Loss of status as a dependent child of the covered employee under the Plan rules	36 months	Dependents

                      
                             
                                       

Yes, disability and second qualifying events. See the section “Other situations during COBRA Continuation Coverage.”

 Early termination of COBRA Continuation Coverage can be the result of any of the following:

• The employer no longer provides any group health coverage for its employees.
• The required initial premium payment was not made in full within 45 days after the election date.
• A monthly premium payment was not made within the 30-day grace period.
• The member became covered under another group health plan or Medicare entitled and after review they were no longer eligible for COBRA coverage.
• A 29-month maximum coverage period ended early due to Social Security Administration determining there was no longer a disability.
• You requested your COBRA coverage be terminated.
• While on COBRA coverage, an event occurred that would be cause for termination of coverage for a person not receiving COBRA coverage (such as fraud). 

No. You will get full credit for any deductibles and out-of pocket costs that were met before COBRA Continuation Coverage. Remember, it’s as if you never lost coverage. COBRA benefit reimbursement follows the provisions of the plan.

Contact your local Human Resources department for more information. The Samaritan Health Services (SHS) Employee Wellness $300 benefit is a benefit you received as an employee, and is not part of your group health coverage benefits. Thus, they are not considered part of COBRA Continuation Coverage. The administration of this benefit is similar to your retirement benefit – they are both administered by the employer.

The law requires employers to provide a newly covered employee and their covered spouse a notice about COBRA Continuation Coverage within 90 days after electing group health insurance coverage. This often happens at the time an employee is newly hired and elects group health coverage from the employer. This notice, General Notice of COBRA Continuation Coverage Rights, is mailed to newly covered members along with two forms: COBRA Qualifying Event or Extension Notification and COBRA Address Notification Form.

This general notice explains the rights of covered individuals to elect group health continuation coverage at the time they experience certain events that result in a loss of coverage. It’s important to understand this notice as it outlines the employee’s responsibility to report certain events. 

Human Resources will report a qualifying event to Samaritan Health Plans (SHP). Within 14 days of receiving that notification, SHP will send an Election Notice packet to the employee, spouse, and/or dependents that will include a COBRA Continuation Coverage Election Notice. This notice gives specifics about how to elect COBRA Continuation Coverage.

In addition to the COBRA Continuation Coverage Election Notice, this election packet also contains:

• COBRA Continuation Coverage Election Form
• COBRA Address Notification Form
• COBRA Premium Rate Sheet
• Flexible Spending Account Continuation Coverage Election Notice (only for members who have an underspent flexible spending account at the time of the qualifying event)

When a qualified beneficiary reports certain second qualifying events during COBRA Continuation Coverage, an Election Notice packet will also be sent. 

All COBRA Continuation Coverage forms needed by qualified beneficiaries can be found on the Member Forms page. The three forms available to qualified beneficiaries include:

COBRA Continuation Coverage Election Form: used by members to enroll in COBRA Continuation Coverage

COBRA Address Notification Form: used by members to provide Samaritan Health Plans current mailing addresses for all COBRA Continuation Coverage members

COBRA Qualifying Event or Extension Notification form: used by members to report specific events

If you are eligible to elect COBRA Continuation Coverage, a premium rate sheet will be sent with your Election Notice packet. If you need additional assistance please call Samaritan Health Plans Customer Service. You can reach them Monday through Friday, from 8 a.m. to 8 p.m. by calling 541-768-4550, 800-832-4580, or TTY 800-735-2900, or in person, Monday through Friday, from 8 a.m. to 5 p.m. at Samaritan Health Plans, 2300 NW Walnut Blvd., Corvallis, OR 97330.

When you received group health coverage as a benefit eligible employee, Samaritan Health Services (SHS) paid the majority of your group health premiums. Once on COBRA Continuation Coverage, you pay the entire premium amount; the portion you were paying previously, as well as the portion contributed by SHS. In addition, federal law allows a 2% administrative fee to help offset the cost of COBRA administration.

There may be other coverage options for you and your family:

• You may be able to buy coverage through the Health Insurance Marketplace. In the Marketplace, you could be eligible for a new kind of tax credit that lowers your monthly premiums right away, and you can see what your premium, deductibles, and out-of-pocket costs will be before you make a decision to enroll. Being eligible for COBRA does not limit your eligibility for coverage for a tax credit through the Marketplace. For more information about health insurance options available through the Health Insurance Marketplace, visit www.healthcare.gov
• You may also want to contact your state to ask if there is a premium payment program that may assist you with the payment of your premiums. Contact your local Department of Human Services office for information.
• Additionally, you may qualify for a special enrollment opportunity for another group health plan for which you are eligible (such as a spouse’s plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days.

Your initial premium payment is due within 45 days of the date you elect COBRA Continuation Coverage. You may make your initial payment at the time you submit your election form, or you may wait to make it after you elect, but before the 45-day deadline. If you send in your initial payment with your election notice, the examples below will help you figure out the amount of your initial payment:

1. If you elect COBRA coverage between the first and 30th day after your loss of coverage, your initial premium payment is one month of COBRA coverage. Your next payment is due on the first day of the following month. For example, if your loss of coverage date is April 30, and you elect coverage May 27, your initial payment should cover the month of May. Your next payment will be due June 1 and must be paid within the 30-day grace period.
2. If you elect COBRA coverage between the 31st and 60th day of your original loss of coverage, your initial premium payment is two months of COBRA coverage (unless you are only electing one month of coverage). Your next payment is due on the first day of the following month. For example, if your loss of coverage date is April 30, and you elect coverage June 18, your initial payment should cover both May and June. Your next payment will be due July 1 and must be paid within the 30-day grace period.

If you do not send your initial payment with your election notice, but pay within the 45 days after you elect, your initial premium payment and any subsequent monthly premiums will be due. The following example assumes your loss of coverage date is April 30 and you elect coverage June 29. If you send in your payment on August 8 (40 days after your election date), at a minimum, your payment should cover the months of May, June, and July. And, your August payment (due August 1) must be paid within the 30-day grace period, by August 31.

If you have questions about the amount of your initial premium payment, call Samaritan Health Plans Customer Service. You can reach them Monday through Friday, from 8 a.m. to 8 p.m. by calling 541-768-4550, 800-832-4580, or TTY 800-735-2900, or in person Monday through Friday, from 8 a.m. to 5 p.m. at Samaritan Health Plans, 2300 NW Walnut Blvd., Corvallis, OR 97330.

After your initial payment is made, the monthly payments are due on the first of each month. However, you have a 30-day grace period to pay the full payment for that month. If you do not make your payment within the 30-day grace period, your coverage will be retroactively terminated to the end of the previous month.

Your premiums can be paid by cash, check, money order or credit card payments. You may either mail or hand-deliver your payment using the addresses below:

Mail to:  
Samaritan Health Plans
PO Box M
Corvallis, OR 97339

Hand-deliver to:
Samaritan Health Plans
2300 NW Walnut Blvd.
Corvallis, OR 97330

Your premium payment by check or money order should be made out to: Samaritan Choice Plans.

You will continue to be covered until your 30-day grace period ends. However, if you fail to make the payment by the end of the grace period, your coverage may, according to current regulations, be terminated retroactive to the last day of the previous month for which the payment was made. If your providers ask about your eligibility during any month when you have not paid by the first day of the month, they will be told that you are benefit eligible, but if you fail to make your premium payment within the grace period you may, according to current regulations, be retroactively terminated to the last day of the previous month.

Yes. Anyone can make your premium payment. It is still due the first of each month and the same 30-day grace period applies. Please ask them to include the payment invoice for that month. If paying by check or money order ask them to write your name in the memo portion. When someone else makes your payment, you should contact Samaritan Health Plans to make sure it was received by the deadline.

You can be terminated early from your COBRA Continuation Coverage.

You have the option to continue to contribute to your flexible spending account (FSA) if you have underspent the amount you already contributed. You may only continue your FSA to the end of the current plan year.

Yes. You may choose to continue your flexible spending account, whether or not you elect to continue any of your other group coverage.

The following chart displays very important deadlines that you must meet to avoid losing your COBRA Continuation Coverage rights:

	Timeline to Report
Report the following Second Qualifying Events To Samaritan Health Plans (SHP): Employee divorce Legal separation A child’s loss of dependent status (for example, child turns 26)	Within 60 days of the later of: Date of the qualifying event Date of loss of coverage due to qualifying event Date member receives Member Handbook
Once you receive the COBRA Coverage Election Notice, if you choose to elect, you must submit a completed COBRA Coverage Election Form to SHP.	Within 60 days of the later of: Date on the notice, or Date you lose group health coverage
If you elect COBRA Continuation Coverage, you must mail or hand-deliver your initial payment to SHP (if you did not send your initial payment with the COBRA Coverage Election Form).	Within 45 days of the date you elect COBRA Continuation Coverage
Your monthly premium payments are due on the first of each month. You must mail or hand-deliver your monthly premium payments to SHP. Qualified beneficiaries may request special enrollment. (For example, in a spouse’s health plan).	By the end of the 30-day grace period   It must be within 30 days of the loss of other coverage (including at the end of the COBRA Continuation Coverage maximum period).
Disability—If you are reporting the disability of a qualified beneficiary, you must send SHP a copy of the Social Security Administration ruling letter.	Within 60 days and before the end of the original 18-month period of COBRA coverage. 60 days from the later of: The date Social Security Administration issues the disability determination The date of the qualifying event The date of loss of coverage The date the qualified beneficiary receives the Member Handbook
No longer disabled-You must report to SHP a Social Security Administration determination that the disabled qualified beneficiary is no longer disabled.	Within 60 days after the Social Security Administration determination was made

 

It could mean a loss of your rights to COBRA Continuation Coverage, losing the coverage after you are already on it, or not getting an 18-month benefit period extended. Depending on the reason, your coverage may, according to current regulations, be terminated retroactively and claims denied back to the termination date.

Yes. You must notify the plan within 30 days of the marriage. However, your spouse is not a qualified beneficiary and only qualifies for COBRA Continuation Coverage as long as you are covered under COBRA. Once your coverage ends for any reason, so does your spouse’s.

Yes. You must notify the plan within 30 days of the birth or adoption. Any child born to a covered employee or placed for adoption with a covered employee is a qualified beneficiary and has all the rights of a qualified beneficiary.

Yes, disability and second qualifying events.

1. A disability determination for any of the qualified beneficiaries in a family can extend the original 18-month period of continuation coverage an additional 11 months (29 months total). To qualify for a disability extension, the qualified beneficiary must:

• Receive a ruling from the Social Security Administration that he or she became disabled before the 60th day of COBRA Continuation Coverage, and
• Send Samaritan Health Plans a copy of the Social Security ruling letter within 60 days and before the end of the original 18-month period of COBRA coverage. The 60 days begins from the latest of the following:

• The date Social Security Administration issues the disability determination
• The date of the qualifying event
• The date of loss of coverage
• The date the qualified beneficiary is informed of the responsibility to notify the COBRA administrator

If these requirements are met, all the covered qualified beneficiaries qualify for an additional 11 months of COBRA Continuation Coverage, as long as the person remains disabled through the entire original 18-month benefit period.

2. Second events can only be considered qualifying events if they would have caused the loss of coverage if the first event had not happened. They can extend the original 18-month benefit period an additional 18 months (36 months total) only for a spouse, ex-spouse or dependent. Second qualifying events include:

• Death of the covered employee
• Divorce or legal separation of the covered employee and spouse
• Medicare entitlement
• Loss of dependent child status under the plan

Members on COBRA Continuation Coverage should use the COBRA Qualifying Event or Extension Notification form located under the Member Forms tab of the Samaritan Choice Benefits page to report the following events:

• Divorce/Legal Separation
• Child Ceasing to Be an Eligible Dependent under the Plan
• Death of Employee
• Covered Employee Entitled to Medicare
• Adding New Dependents
• Social Security Disability
• Ceasing to be Social Security Disabled
• Other Coverage or Medicare Entitlement