Ceridian COBRA Continuation Services Table of Contents I Welcome to Ceridian COBRA Continuation Services 3 A. What Ceridian COBRA Continuation Services Does 4 B. What the Employer Does 5 C. COBRA Compliance Requirements 6 D. Ceridian COBRA Process 1. Qualifying Events 7 2. New Hire Notifications 8 3. Total Population Service (Optional Service) 8 4. HIPAA Notification Service of an Active Loss (Optional Service) 8 II Ceridian Web Capabilities 9 A. Web access for Participants 9 B. Web access for Employers 10 C. Ceridian's WebQE Product 10 D. Reports available via the Web 11, 12 III WebQE COBRA Procedures 13 A. COBRA Rate Sheet 13 B. COBRA Qualifying Event (QE) or Takeover 13 C. New Hire Notification 14 D. Print a Report for Your Records 14 IV. Frequently Asked Questions 15 A. [NOTICE ISSUES] How will I know if there are problems 15 once I enter a COBRA event through the Web? B. [TIMING OF NOTICES] I just entered a Qualifying Event through the Web; now what? 15 C. [ELECTION PROCESS] How does the Election Process work? 15 D. [PREMIUMS] What about Premiums? 16 E. [MONTHLY REPORTS] Do I receive monthly reports for 16 my COBRA account? F. [CLIENT BILLING] How am I billed for these services? 16 Page 1
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Ceridian COBRA Continuation Services
Table of Contents
I Welcome to Ceridian COBRA Continuation Services 3
A. What Ceridian COBRA Continuation Services Does 4
B. What the Employer Does 5
C. COBRA Compliance Requirements 6
D. Ceridian COBRA Process
1. Qualifying Events 7
2. New Hire Notifications 8
3. Total Population Service (Optional Service) 8
4. HIPAA Notification Service of an Active Loss (Optional Service) 8
II Ceridian Web Capabilities 9
A. Web access for Participants 9
B. Web access for Employers 10
C. Ceridian's WebQE Product 10
D. Reports available via the Web 11, 12
III WebQE COBRA Procedures 13
A. COBRA Rate Sheet 13
B. COBRA Qualifying Event (QE) or Takeover 13
C. New Hire Notification 14
D. Print a Report for Your Records 14
IV. Frequently Asked Questions 15
A. [NOTICE ISSUES] How will I know if there are problems 15once I enter a COBRA event through the Web?
B. [TIMING OF NOTICES] I just entered a Qualifying Eventthrough the Web; now what? 15
C. [ELECTION PROCESS] How does the Election Process work? 15
D. [PREMIUMS] What about Premiums? 16
E. [MONTHLY REPORTS] Do I receive monthly reports for 16my COBRA account?
F. [CLIENT BILLING] How am I billed for these services? 16
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G. [DISHONORED CHECKS] How are bad checks handled? 16
H. [CAL-COBRA] What is Cal-COBRA, and can Ceridian assist 17with that administration?
I. [INITIAL/GENERAL NOTICE] I don't think that my current 17employees have ever been provided their Initial Notice ofCOBRA Rights letter. Can you help me with that?
J. [CLIENT FEES-SURCHARGE] In my sales contract there is 17reference to a surcharge. What is that?
K. [ELIGIBILITY REPORTING] Can Ceridian notify my 17carrier/insurer of changes to my COBRA participants?
L. [SHORT PAYMENTS] What is Safe Harbor? 18
M. [NOTICE TIMEFRAMES] What are the timeframes to submit 18COBRA (Qualifying event and New Hire/Initial/General notices)events to Ceridian?
N. [PRORATING PREMIUMS] My employees' benefits end on 18their last day of work, but I want everyone on the same billingcycle, how can this work?
O. [CLIENT FEES] Can the monthly COBRA fee be taken from 18the COBRA participant's premiums?
P. [CERIDIAN CONTACTS] Who should clients contact at Ceridian? 19
V Notification FormsA. Takeover Form 20
B. Qualifying Event Form 21
C. New Hire Notification Form 22
VI Sample Reports A. Participant Update Sample Report 23, 24 B. Participant Status Sample Report 25, 26
Welcome to Ceridian COBRA Continuation Services — the nation’s largest COBRA administration service. By choosing us, you have chosen not just our expertise in COBRA administration, but also to let us handle the details for you, allowing you to focus on your most pressing business requirements.
Members of our implementation team will be contacting you. They will review the materials in this "Welcome to Ceridian COBRA Continuation Services" section, and the section entitled "Ceridian COBRA Continuation Services Forms," and discuss how Ceridian can best meet your needs. Our team will show you just how well they know COBRA — and will share their knowledge with you as Ceridian assumes the task of managing your compliance program.
Ceridian does it all, from assuming administration of your COBRA continuants, to performing future billing and adjudication of eligibility, to collecting and processing all related transactions.
With Ceridian, your role is reduced to responding to 3 situations:
• When individuals first become covered under your plan.
• When an individual experiences a COBRA Qualifying Event.
• If you receive a report of COBRA activity that requires response.
In this document, you will find information concerning:
1. What Ceridian Does
2. What the Employer Does
3. Reports and Updating Your Carrier
4. COBRA Compliance Requirements
5. COBRA Compliant Forms
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What Ceridian COBRA Continuation Services Does Elections • Ceridian Customer Service Representatives (CSRs) respond to all inquiries from Qualified Beneficiaries.
Our CSRs respond to employer questions through a toll-free help “Hotline.”
• Ceridian provides a toll-free hotline to the Interactive Voice Response system (IVR) for continuants to make premium inquires 24 hours-a-day, 365 days a year.
• Qualified Beneficiaries can elect COBRA on our Web site using Elect By Net; by phone via the IVR system; or on paper with a COBRA Election Form.
• Ceridian determines whether the elections COBRA Services receives were made within the allowable 60-day period.
• Ceridian offers special status reports to employers on the Web or IVR
Billing • Ceridian administers the initial 45-day and ongoing 30-day grace periods.
• Each month, Ceridian sends each continuant a detailed bill with a payment envelope.
• Ceridian determines any late premium payments. Partial payments cannot be accepted. However, Ceridian does provide “Safe Harbor” notifications for insignificant short payments as defined by the COBRA regulations.
• Ceridian follows up on dishonored checks.
• Ceridian sends a “Notice of Early Termination” to those who do not pay their premiums within the grace period.
• If you have active continuants, you will receive a monthly consolidated premium check representing premiums collected from COBRA continuants, less the two percent administrative fee paid by the continuant. Accompanying reports will indicate actions to be taken, if any.
As part of our COBRA administration, Ceridian:
• Sends date of maximum COBRA coverage notice, including conversion language, where appropriate, in the last 180 days before the date of COBRA exhaustion.
• Accepts calls from providers, hospital or HMOs regarding coverages/eligibility.
• Handles multiple Qualifying Events (for example, termination of employment followed by divorce).
• Provides additional forms and rate reports, if needed and makes them available on our Web site
• Ceridian archives critical documents and materials for seven years in a professional archiving facility, to resolve potential dispute.
Additional Services
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What the Employer Does
NotificationsIf you are using our New Employee Notification or Total Population services, Ceridian will send the General Notice of COBRA Rights to your covered employees and their covered spouses when they first become covered under the plan. If you are not using these services, you must provide these notices typically by first class mail to their last known home address. This notice must be addressed to the covered employee and covered spouse.
When a Qualifying Event occurs, a Qualifying Event Notification must be provided to the Qualified Beneficiary(ies) typically by first class mail to the last known home address. The employer must notify the Ceridian COBRA Services Center about the Qualifying Event.
Ceridian generates various reports to keep you apprised of COBRA-related activities involving Qualified Beneficiaries. Your role is to review the information and take any action that may be indicated.
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Who has to Comply? Every employer (except "church groups") who maintains a group health insurance plan, and who employs 20 or more full- and/or part-time employees during 50 percent of the business days in the preceding calendar year or as further defined under the 2001 Final COBRA Regulations. Notification of Rights 1. The employer or the plan administrator must notify every employee and every covered spouse of all of their rights under COBRA within 90 days of when they first become covered under the group health plan. Separate notices must be sent if separate residences are maintained. This applies to all current and future employees and covered spouses. 2. Each time a Qualifying Event occurs, the employer must, within 14 days of notification to the Plan Administrator, notify each Qualified Beneficiary of his/her continuation rights, benefits and premium rates for the plan(s) in which they're eligible. For either kind of notification, good faith compliance has been defined as First-Class Mail, addressed to both the employee and spouse and sent to the last known home address. If covered dependents live at a separate address, separate notifications must be sent. Election Rights When a Qualifying Event causes loss of coverage, the employer must allow continued coverage under the group health plan for up to 18 months in the case of termination of employment or reduction in hours, or up to 36 months for a dependent Qualifying Event. A second Qualifying Event that causes a loss of coverage under the group health plan for a dependent occurring during the 18-month coverage period of the first Qualifying Event expands the original period to 36 months. What is a Qualifying Event? Any of the following events causing a loss of coverage by a Qualified Beneficiary under the plan: 1. Termination (other than for
gross misconduct) of the employee's employment, for any reason (layoff, resignation, retirement, etc.)
2. Reduction of hours worked by employee
3. Death of the employee 4. Divorce or legal separation
COBRA Compliance Requirements
5. Dependent child ceasing to meet
eligibility requirements 6. Dependent coverage is lost because
the active employee (or COBRA continuant) becomes entitled to Medicare.
7. Retiree or retiree's spouse or child loses coverage within one year before or after the commencement of proceedings under Title 11 (bankruptcy), United States Code of the sponsoring employer.
Who is a Qualified Beneficiary? Any employee, spouse or dependent child who was covered on the day before the Qualifying Event and who would otherwise lose coverage under the plan because of the Qualifying Event. This definition also includes a child born to or placed for adoption with a covered employee during the period of COBRA coverage. Election Timeframe Qualified Beneficiaries are allowed to buy continuation coverage retroactive to the benefit termination date. They are entitled to make this election within 60 days of the date of the notification of their rights or the date that benefits would terminate, whichever is later. If they decline, they may change their minds and elect— if they are still within the 60-day election period. Choices of Coverage Each Qualified Beneficiary must be allowed to make an independent election. For example, if the plan contains medical and dental coverage, the employee may decline coverage, the spouse may elect medical only, and the child may elect medical and dental. Dependents You must allow 'branching" of coverage. If a continuant elects family coverage, his or her dependent(s) are allowed to continue benefits if/when they would otherwise cease to be eligible under the contract as dependents during the 18- 36-month continuation period. Qualified Beneficiaries other than the covered employee may continue coverage for up to 36 months from the date of the covered employee's Medicare entitlement, if the covered employee becomes entitled to Medicare and, within 18 months thereafter, has a Qualifying Event. You must allow continuants to add dependents if the dependents meet the special enrollment rules under the Health Insurance Portability and Accountability Act (HIPAA) or if the continuants acquire any new dependents after their Qualifying Event — if such a right applies to similarly situated active employees.
Ongoing Administration You must allow continuants to change benefits annually if the option is available to active employees (i.e., flexible benefits plans/HMO dual option plans). Open Enrollment periods must be allowed for continuants on the same basis as for active employees. Continuants must be offered a conversion privilege at the end of the 18- or 36-month period, if one is available to active employees. You must allow existing COBRA continuants to continue coverage as long as they meet the eligibility requirements, even if your group size falls below 20 full-time and/or part-time employees. Payments The employer or plan administrator must all continuants to pay their first premium within 45 days of the date they elect coverage, if coverage is elected within the 60-day election period. You may not require any premium payment until 45 days from the date of election. You must allow a grace period of not less than 30 days for the payment of all subsequent premiums. Disability Extension A Qualified Beneficiary's (and that of any other covered members of the family) continuation period must be extended to 29 months from 18 months if the Social Security Administration determines that the Qualified Beneficiary was totally disabled under Title 11 or XVI of the Social Security Act on the day of the Qualifying Event, or within the first 60 days of COBRA coverage, and the Qualified Beneficiary sends a copy of the determination notice to Ceridian before the end of the initial 18-month period and within the later of 60 days of the date of the notice from the SSA; the qualifying event date; the benefit termination date; or the date of the notice to the qualified beneficiary of the rules of the notice. Other Coverages You must allow continuant(s) to continue COBRA coverage despite their becoming covered under a new group health plan if the new plan contains an exclusion or limitation with respect to any pre-existing condition of that continuant. See Your Attorney The complexity of the law — and the fact that judicial decisions affecting compliance can happen at any time — precludes a complete description of legal requirements. Please consult your attorney.
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Ceridian COBRA Process
I. Qualifying Events1. New Qualifying Event - Client contacts carrier(s)/insurer(s) and terminates coverage.
2. Client sends Ceridian event information via Web, download, or manual form within 14 days of the notice to the Plan Administrator as a result of the qualifying event.
3. Ceridian sends Notice of a Qualifying Event (First Letter) to the Qualified Beneficiaries offering same coverage that was lost as a result of the Qualifying Event.
4. Gives 60 days to elect COBRA coverage, determined by date election made. (Typically, timely election is determined using the U.S. postmark.)
5. If election is made without payment, Ceridian sends invoice with 45 day grace period from the date of election.
6. If election is made with payment, Ceridian will fax a Participant Update Report (PUR) to client. Immediately fax this form to your carrier(s)/insurer(s) to reinstate participant.
7. If no election is made within 60 days, there is nothing else to do at this point.
8. Cancelled records - If participant is cancelled for non-payment, Ceridian will fax a Participant Update Report to client. Immediately fax this form to your carrier(s)/insurer(s) to terminate coverage.
9. Maximum Coverage Letter - Sent 90 days prior to the date of exhaustion of COBRA coverage.
10. Invoices are mailed to participants around the 19th of each month.
11. Monthly reports are provided within the first ten business days of each month following activity. The reports can be viewed on www.ceridian-benefits.com monthly after the processing has completed.
12. Participant Status Report is included in the Monthly Report and recaps all activity for the month, including all new events, terminations, change in status, address changes, etc.
13. Premium Distribution Report is included in the Monthly Report and is broken down by carrier, and participant name and social security number, and reflects payments made to Ceridian, minus the 2% administration fee. A check is included representing total of money collected for the month.
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II. New Hire Notifications 1. Client sends New Hire information via the WEBQE, download, or manual form within the first 90 days after the employee or spouse becomes covered by one of your COBRA eligible plans. 2. Ceridian sends notification to the employee or the employee and spouse, by name. Notification to the covered spouse is considered notification to the covered dependents. III. Total Population Service (Optional Service)
1. Clients send in completed Excel spreadsheet via email to their Implementation Specialist or Client Services at [email protected] for all of their covered employees who have not received an Initial Notice of COBRA Rights. 2. Ceridian sends the Initial Notice to the covered employee or the covered employee and covered spouse. IV. HIPAA Notification Service of an Active Loss of Coverage (Optional Service) 1. Client sends HIPAA information to Ceridian via WEBQE, download or manual form when a covered employee or dependent loses medical coverage. 2. If the person is to be offered COBRA and a manual form is sent, additional information will be necessary and is requested on the COBRA/HIPAA Qualifying Event form. 3. Ceridian sends the HIPAA Certificate (Certificate of Creditable Coverage) to the employees and all dependents losing medical coverage, if the information is included in the notice received by Ceridian.
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Ceridian Web CapabilitiesCeridian offers online access to account information to both employers and participants. Our Web address is www.ceridian-benefits.com. This access to comprehensive, up-to-date information on the status of Qualified Beneficiaries has resulted in improved service and convenience. The information contained on our Web site is secure and protected by password authentication.
Web access for Participants:Ceridian's Web site provides participants with many self-service opportunities. COBRA participants can change their address on the screen and modify information about their dependents that are eligible for COBRA. Ceridian also offers an Elect-by-Net service whereby Qualified Beneficiaries can elect COBRA coverage via the Internet up to two days prior to the election expiration date. Qualified Beneficiaries are able to log into the Web site to make their COBRA election, change their address, add or drop dependents and cancel coverage.
Each Qualified Beneficiary/participant is provided with an account summary that includes generalinformation, billing/payment status and coverages.
The General Information section includes: current date of the information; Qualifying Event date; COBRA status; gender; date of birth; company, division, and unit; continuant address; date COBRA coverage began; date COBRA eligibility ends; first COBRA payment date (date received by Ceridian); and paid-through date.
The Billing and Payment Information section includes: date the last payment was received; last payment amount; next premium due date; amount of the premium; credits (if any); amount due, and paid-through date.
The Coverage Summary includes: insurance carrier code; plan name; family status (beneficiary/dependents); group number; coverage begin date; and coverage end date.
Dependent Information includes: name; social security number; date of birth; gender; relation to beneficiary; coverage begin date; and coverage stop date.
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Web Access for EmployersCeridian’s comprehensive Web site offers employers options for submitting new Initial Notifications and Qualifying Events via the Internet, as well as obtaining information about their current COBRA population. Employers access all these features using a single sign on at the following screen:
Ceridian’s WebQE This service allows employers to notify Ceridian via the Internet when a Qualifying Event takes place. WebQE is the most advanced COBRA notification system in the industry. New Qualifying Events can be completed in moments via our Web site. We have provided maximum flexibility and real-time access with WebQE. This paperless means of notifying Ceridian of Qualifying Events is fast, secure, and user-friendly. A sample screen shot is below:
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Ceridian also provides access for employers to check on Continuant status and to generate status reports on their COBRA population.
Reports available via the Web include:
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Employers can also search for participant information individually using many different parameters. A sample screen shot is below:
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WebQE COBRA ProceduresIt is not necessary to validate entries as the site will not allow advancing to the next page if an error has occurred. The errors will appear in red at the top of the page.
A. COBRA Rate Sheet Go to Client Reports
COBRA Rate Report-Reg Rates
Easy View, Latest Rates at the bottom of the page and submit.
Change the printer to Landscape and print.
B. COBRA Qualifying Event (QE) or Takeover Log in using your assigned USER ID and Password.
Select COBRA/BBS/SCS ADMIN using the dropdown list on the upper left corner and click “OK”.
Choose Ceridian COBRA services from the lower left dropdown list.
Move your cursor to select Data Entry Forms within the Yellow Tool Bar.
Left double click COBRA Qualifying Event to notify Ceridian of a COBRA qualifying event or COBRA Billing Takeover if you want Ceridian to begin administering COBRA for a continuant who is actively on COBRA.
Select and complete the reason for the termination, double click on next.
Enter the SSN with the dashes. Add the Benefits termination date using the format shown. Go to the bottom of the page click on next.
Enter name, address etc. If the employee has dependents enter them at the bottom of the page by clicking on the add button. Medical Wait Begin Date is the Hire Date; the Medical Coverage is how long the employee has to wait before beginning his coverage. Go to the bottom of the page click on next.
Populate the benefit coverages using the drop down box, click on next.
Deselect the coverages: if the dependents did not take the same benefits the employee took then deselect. Go to the bottom of the page click on next.
At the Summary page after submitting the document, Click “Print”.
If you have additional QE’s to fill out after you receive verification that your document was received by Ceridian, press new document button. Please note the following:
• Qualifying Event Date= the last day the qualified beneficiary is eligible to continue on the group health plan (last day of work).
• Benefits Termination=the last full day of benefits under the qualified beneficiary’s active group plan.
• Medical Wait period Begin Date =Date of Hire.
• Medical Coverage Begin Date=the first day of active group coverage.
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C. New Hire Notification
(Disclaimer - this is an optional service and may not be available to all clients.)
• Click on the box that pertains to the new hire. Double Click on next.
• Enter the SSN with the dashes. Double Click on next. Do not validate.
• Fill out the personal information. Double Click on next. Do not validate.
• A Security Information box will appear, Left click “Yes” to accept that “This page contains both secure and non secure items.”
• Your form entry is complete. Click “SUBMIT”, the Document Received window will then display advising the form was successfully submitted, click “OK.”
D. Print a Report for Your Records
• Press the Back arrow on your Web browser at the top of the screen.
• Move your cursor to select Client Reports, then Online Data Entry Reports.
• Left click on “COBRA Rights Notification, Qualifying Event, or Takeover.”
• Enter today’s Date in the “From:” and “To:” Date lines and click “Submit.”
• To Print: left Click “File” and “Print” in the top toolbar.
For benefits administration assistance, please contact Ceridian Benefits’ Client Services.
For technical questions, please contact Ceridian Technical Support using our toll free number 1-800-469-0429 or email us at [email protected].
Technical Web SupportCeridian Corporation3201 34th Street SouthSt. Petersburg, FL 33711
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Frequently Asked Questions
A. [NOTICE ISSUES] How will I know if there are problems once I send in a COBRA event through the Web?
• In the event Ceridian is unable to mail the COBRA notification kit due to incomplete participant data; the Ceridian Processing Support Department will contact the client for follow-up by sending an urgent email or fax requesting a response within three business days.
• The Client’s immediate response is pertinent to Ceridian providing quality service to our clients.
• If no response is received a second email or fax will be sent advising that no response was received. The record will be cancelled and no further action will be taken.
• A Participant Change Form will be required in order to change or revise a participant record once submitted via the Web site. This form will be provided by the Implementation Specialist setting up your account.
B. [TIMING OF NOTICES] I just sent in a Qualifying Event through the Web; now what?
Upon notification, within 24 hours, a COBRA notification package with an Election form is mailed via first class with proof of mailing to the participant. (Paper forms may take up to 5 business days to process)
The participant is given 60 days to elect COBRA coverage either from the Benefits Termination Date, which is the last day covered under your group health plan, or the Date of Notice, whichever is later.
Participants have three methods to elect COBRA:
o Web site (Elect By Net) – Participant can access his or her account online.
o Elect by phone via the Interactive Voice Response system. (Elect as offered) Available 24/7.
o Mail the Election form to Ceridian.
All information and instructions are included in the COBRA notice along with a toll free Customer Service number should they need any assistance.
C. [ELECTION PROCESS] How does the Election Process work?
If the participant elects without payment, Ceridian will mail the first invoice with a 45 day grace period from the date of election.
Upon the receipt of both the election and payment, Ceridian will generate a Participant Update Report to notify the client the participant needs to be re-enrolled on your group health plan(s).
This notification can be sent in one of two methods:
o Faxed – will be faxed to client contact daily, per participant
o Mailed – will be mailed weekly, (summary of weeks activity)
Upon request Ceridian can suppress these notifications or if Eligibility Reporting Services have been purchased, Ceridian will send reports directly to the insurer and the client will not need to action the Participant Update Report.
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D. [PREMIUMS] What about Premiums?
Ceridian mails monthly invoices to participants on or about the 19th of the current month for the subsequent month's billing, giving the allowed 30 day grace, unless the plan sponsor has indicated a greater grace period applies for the group health plan(s).
If payment for the current month is not received at the time of the next month’s premium bill, the invoice will include the outstanding balance due for the current month and grace date, and a Grace Period Reminder notice advising of the approaching grace date.
If the full payment is not postmarked on or before the grace date, coverage is cancelled and a Participant Update Report is generated and sent to the client contact to notify of the cancellation of the participant’s coverage. If Ceridian is reporting eligibility, the insurer will be notified on the next eligibility report.
E. [MONTHLY REPORTS] Do I receive monthly reports for my COBRA account?
Monthly Status Reports are generated within the first ten business days of the month for the prior month’s activity. The reports are available for review on the Ceridian Web site after the reports are generated. This timeframe is necessary to accommodate the review and processing time of end of month postmarked timely premium payments. Reports will be available for review for three months, and can be downloaded to Excel.
The Monthly Participant Status Report (PSR) summarizes the previous month’s activity; broken down by new elections without payment, new elections with payment, cancellations, and addition/deletion of dependents. It is a snapshot of your COBRA population.
Note: Review this report thoroughly to ensure an accurate accounting of all Qualified Events submitted. If not please contact Client Services to discuss.
The Premium Distribution Report (PDR) lists each participant beneath his or her insurer, indicates the payment cycle, and payment received excluding our 2% administrative fee and amount disbursed back to you or to your insurer. The PDR is collated by insurer and can be sorted by division or unit if required.
The premium distribution check will accompany the PDR report; unless premiums are disbursed to the insurer, then the report will register the amount disbursed to your insurer(s).
F. [CLIENT BILLING] How am I billed for these services?
Clients are invoiced on the last day of each month for services provided for that month.
Invoice backup detail is available on the Web site (www.ceridian-benefits.com.)
Ceridian also offers APS, Automated Payment Service; if authorized, Ceridian will originate an Automated Clearing House (ACH) direct debit to pay your company's monthly service fees from your bank account.
G. [DISHONORED CHECKS] How are bad checks handled?
Ceridian accepts all payments in “good-faith”.
In the event a participant’s check is dishonored, a notification of dishonored check letter is immediately sent to the client and participant.
If the funds are still at Ceridian, the amount of the dishonored check is removed from the record.
If the funds are no longer at Ceridian, the client may instruct us to terminate the COBRA record and return the funds to Ceridian in order to recover the amount of the dishonored check.
If the client instructs Ceridian to continue COBRA coverage, and the amount of the dishonored check is not repaid to Ceridian within 30 days, the matter will be referred to a collection agency.
If the collection agency is unsuccessful, Ceridian will bill the client for the funds already disbursed directly to the client and/or insurer. Page 16
H. [CAL-COBRA] What is Cal-COBRA and can Ceridian assist with that administration?
Participants must reside in or work in the California and be enrolled in a California eligible insured health plan.
Participants may qualify to extend COBRA benefits an additional 18 months after the exhaustion of COBRA.
Medical carrier administers this extension according to the state continuation requirements.
Self insured plans are exempt.
Cal-COBRA is a mandated administrative function for insurers that offer a California eligible health plan, such as an HMO. An employer’s only obligation under the law is to notify their Federal COBRA participant’s of how to apply for state Cal-COBRA benefits when their Federal COBRA benefits are exhausted if their insurer has a California eligible health plan.
Ceridian will include this required notification at the same time we notify Federal COBRA participants that their COBRA rights are about to end due to the exhaustion of COBRA coverage. This notice will typically occur 90 days prior to exhaustion of COBRA benefits, and well before the typical 30-day advance notice timeframe specified by most insurers.
Please note: Ceridian must be notified of which plans must comply with Cal-COBRA or the COBRA maximum coverage letter will not include any reference to Cal-COBRA.
I. [INITIAL/GENERAL NOTICE] I don’t think that my current employees have ever been provided their Initial Notice of COBRA Rights letter. Can you help me with that?
Ceridian does offer additional services for employers designed to bring them into compliance with Federal COBRA.
For a fee, Ceridian will be able to provide the Initial Notice of COBRA Rights letter to all current employees covered by a COBRA eligible plan, who have not previously been provided that notice.
Please ask the Implementation Specialist for additional information.
J. [CLIENT FEES-SURCHARGE] In my sales contract there is reference to a surcharge, what is that?
The monthly service fee charged by Ceridian is based on the number of employees enrolled under COBRA eligible health plans provided to Ceridian at the time of the sales agreement.
Based on that number, Ceridian calculates the amount of COBRA qualifying events that should take place throughout the year.
The surcharge is the amount charged, per event that exceeds that annual amount set forth in the sales contract. This is based on 20% of covered employees.
This is not applicable to all groups; please check the sales contract for monthly charges.
K. [ELIGIBILITY REPORTING] Can Ceridian notify my insurer/carrier of changes to my COBRA participants?
Ceridian offers services designed to make COBRA administration as easy and affordable as possible.
Ceridian can add services including Eligibility Reporting directly to health insurers/carriers.
This is a premium service; and additional fees will apply.
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L. [SHORT PAYMENTS] What is Safe Harbor?
The COBRA federal guidelines provide a Safe Harbor provision for continuants to make up a billing shortfall.
Continuants that make partial payments that are up to ten percent less than the amount owed, not exceeding $50.00, are given a 30-day grace period to make the remainder of the payment. M. [NOTICE TIMEFRAMES] What are the timeframes to submit COBRA (Qualifying Events and New Hire/Initial/General notices) events to Ceridian?
The Initial Notice of COBRA Rights (New Hire Notice) should be submitted to Ceridian no later than 90 days after the employee and /or their dependents first become covered under a COBRA eligible plan.
The Qualifying Event form (offering COBRA) should be submitted no later than 14 days from the date the Plan Administrator is notified of the employee’s or eligible dependent’s qualifying event. N. [PRORATING PREMIUMS] My employee’s benefits end on their last day of work, but I want everyone on the same billing cycle, how can this work?
Ceridian is able to prorate the premiums for your employees during their first and last months of COBRA.
This way all of your employees will have their due dates on the first of the month for their COBRA (i.e., July 1st is the due date for July premiums). O. [CLIENT FEES] Can the monthly COBRA fee be taken from the COBRA participant’s premiums?
No.
The premiums collected from the participants are disbursed to the client (employer) at the end of each monthly billing cycle.
For the monthly COBRA Service fee, a separate invoice is sent approximately the 8th of each month.
Please remit a check, or, as an alternative, payment can be made by having an Automated Clearing House (ACH) direct debit set up to have Ceridian automatically debit these funds from your designated bank account. Please contact your COBRA Implementation Analyst for ACH authorization forms to set up this payment method.
Clients are billed on the last day of the month for the prior month’s administration fees. Example: Clients are billed at the end of November for November administration fees.
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P. [CERIDIAN CONTACTS] Who should clients contact at Ceridian? Important 800 numbers: Client Customer Service toll free number is 866-221-9214, or by email at [email protected]. Representatives are available between the hours of 8:00 a.m. to 8:00 pm ET, Monday through Friday. Ceridian Technical Support 800-469-0429 or via email at [email protected] Who should COBRA participants or eligible employees contact for assistance? Participant Customer Service can be contacted by email at [email protected] or by phone and the toll free number is 800-877-7994. The Interactive Voice Response (IVR) system is available 24/7 for COBRA participants. Customer Service Representatives are available 8:00 a.m. to 8:00 p.m. ET Monday through Friday. Ceridian COBRA Services payment address: P.O. Box 534099, St. Petersburg, FL 33747 NOTE: Please do not refer COBRA participants to the Client Service number. Participants will be directed back to Participant Customer Services.
1b) Division or Region Code 1c) Company ID or Unit Code
(If applicable, refer to the Client Rate Report for the one character or twocharacters required [alpha and/or numeric] to complete 1b and 1c above.)
2) Ceridian COBRA Services Account # (indicated on the Client Rate report for location orsubsidiary)
3) Please be advised that the following has had a Qualifying Event.(check one) (E)mployee (D)ependent
4) Social Security Number of Continuant who elected coverage
5a) Name of COBRA Continuant (last, first, mi)
5b) Street (include apartment number)
5c) City
5d) State 5e) Zip Code
6) Home Phone # (if available)
7) Employee Number (if applicable)
8) Date of Birth 9) Gender (check one)
10) Marital Status (check one)
11) If the Continuant listed in box #5a is not the employee, enter the following:Employee Name (last, first, mi) _______________________________________
Employee SSN
Dependent’s Relationship to Employee _________________________________
12) Qualifying Event Date
13) Last day of pre-COBRA Coverage (cannot be prior to Qualifying Event Date)
14) First premium due-date for which Ceridian is to bill.
15) COBRA Qualifying Event that caused loss of coverage (check one)Continuation of coverage for 18 months:
Employee’s termination of employment (includes voluntary resignation,involuntary termination [except when termination is due to gross misconduct],retirement, layoff or leave of absence) (Code 1)
Employee’s reduction in work hours (includes work stoppage or strike) (Code 2)
Continuation of coverage for 36 months:Death of covered employee /retiree (Code 3) Ineligibility of dependent child (Code 6)
Divorce/legal separation (Code 4) Retiree, spouse or child of retiree losesCovered employee/retiree becomes coverage within one year before or afterentitled to Medicare; dependents commencement of proceedings by
sponsoring employer under Title 11
16) If employee, does he/she have a health care Flexible Spending Account (FSA)? (N)o (Y)es (If yes, MONTHLY contribution $______________________)
17) Refer to your Rate Report and enter the current Carrier Code, Option Codeand Plan Code for each coverage elected.
* Select from the following current Plan Code coverages — Ceridian administersPlan only Code coverage options that are permitted by your plan or carrier:1 = Individual 3 = Family 14 = Individual + Child2 = Individual + 1 9 = Individual + Spouse 15 = Individual + Children_______________ _______________ _______________
18) Has the Continuant been approved for an additional 11-month disability extension? (N)o (Y)es
19) Subsidy Applies? (check one) (N)o (Y)es
Subsidy Begin Date:
Subsidy End Date:
20) If the COBRA Continuant has dependent(s) covered, please complete the section below (please provide last, first and middle initial for the name):
Dependent Name ______________________________________________________Social Security Number______________ —__________—_______________Date of Birth (month/day/year) ________________________________________Gender (M)ale (F)emaleRelationship to employee ________________________________________________Covered under group health plan on day of Qualifying Event? (check one) (Y)es (N)o
Dependent Name ______________________________________________________Social Security Number ______________ —__________—_______________Date of Birth (month/day/year) ________________________________________Gender (M)ale (F)emaleRelationship to employee _________________________________________________Covered under group health plan on day of Qualifying Event? (check one) (Y)es (N)o
Dependent Name ______________________________________________________Social Security Number ______________ —__________—_______________Date of Birth (month/day/year) ________________________________________Gender (M)ale (F)emaleRelationship to employee _________________________________________________Covered under group health plan on day of Qualifying Event? (check one) (Y)es (N)o
INSTRUCTIONS: Please type or print, IN BLACK OR BLUE INK, clearly.• Fill out just one form per family unit (Qualified Beneficiary and dependents).• Use this form to report existing COBRA continuants who will be transferred
to Ceridian.• Please do not use this form to report new Qualifying Events. Use the Qualifying
Event Notification Form.COMPLETE THIS FORM AND RETURN IT TO:Ceridian COBRA Services Center, P.O. Box 534066, St. Petersburg, FL 33747-4066Telephone: 800-488-8757 • Fax: 727-865-3648
Prepared By:Name: (Print)
Date:
Phone #:
Fax #:
COBRA Continuant Takeover Form(For transferring current COBRA continuants to Ceridian)
(S)ingle (M)arried (W)idowed (D)ivorced
ORIGINAL NOTICE If FAXED, do not mail copy.REVISION . . . to a form that was previously sent.
may elect continuance of identicalcoverage (Code 5)
M M D D Y Y Y Y
M M D D Y Y Y Y
Retiree, spouse or child of retireeloses coverage within one year beforeor after commencement of proceedingsby sponsoring employer under Title 11(bankruptcy) United States Code (Code 7)
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16) COBRA Qualifying Event that caused loss of coverage (check one)Continuation of coverage for 18 months:
Employee’s retirement (Code 8) Employee’s reduction in hours (Code 2)
Employee’s involuntary termination (Code C) Employee’s begins leave of absence (Code 9)
Continuation of coverage for 36 months:Divorce/legal separation (Code 4) Death of covered employee /retiree (Code 3)
Ineligibility of dependent child (Code 6) Retiree, spouse or child of retiree losesCovered employee/retiree becomes coverage within one year before orentitled to Medicare; dependents after commencement of proceedings by
sponsoring employer under title 11(bankruptcy) United States Code (Code 7)
17) Spouse/Dependent Information. Each name should include last, firstand middle initial.Name of Spouse____________________________________________Social Security Number
Date of Birth
GenderAddress (if different from participant) _______________________________________________________________________________________________________
Name of Dependent_________________________________________Social Security Number
Date of Birth
Gender Male FemaleAddress (if different from participant) _______________________________________________________________________________________________________
Name of Dependent___________________________________________Social Security Number
Date of Birth
Gender Male FemaleAddress (if different from participant) _______________________________________________________________________________________________________
Name of Dependent_________________________________________Social Security Number
Date of Birth
Gender Male Female
Address (if different from participant) ________________________________
Please see Addendum if additional names need to be listed in this sectionPrepared ByName: (PRINT)________________________________________________Date:
Telephone #
Fax #
1a) From (Company)
1b) Division or Region Code 1c) Company ID or Unit Code
(If applicable, refer to the Client Rate Report for the one character to twocharacters required [alpha and/or numeric] to complete 1b and 1c above.)
2) Ceridian COBRA Services Account Number
3) Please be advised that the following has had a Qualifying Event. (check one)
4) Social Security Number of Qualified Beneficiary
5a) Qualified Beneficiary’s Name (last, first, mi)
5b) Street (include apartment number)
5c) City 5d) State 5e) Zip Code
6) Home Phone # of Qualified Beneficiary (include Area Code) 7) Employee # (if applicable)
8) Date of Birth of Qualified Beneficiary 9) Gender (check one)
10) If the Qualified Beneficiary listed in box #5a is not the employee, enterthe following:Employee Name (last, first, mi)_________________________________________
Employee SSNDependent’s Relationship to Employee _____________________________
11) Qualifying Event Date
12) Last day of pre-COBRA Coverage (cannot be prior to Qualifying Event Date)
13) Is this a second Qualifying Event for a dependent who is currentlyon COBRA? (N)o (Y)es
14) If employee, does he/she have a health care FSA? (N)o (Y)es (If yes, MONTHLY contribution $_____________________)
15) Refer to your Client Rate Report and enter the current Carrier Option, OptionCode and Plan Code for each coverage in effect on the Qualifying Event Date:
*Select from the following current Plan Code Coverages. Ceridian administers onlyPlan Code coverage options that are permitted by your plan or carrier:
SAMPLE - Participant Update Report Fax Facsimile Cover Sheet Ceridian COBRA Continuation Services To: JANE SAMPLE, CBS SALES DEMO COMPANY Fax No: 727-555-1212, Voice No: 727-555-1212 From: Ceridian COBRA Continuation Services 3201 34th Street South St. Petersburg, FL 33711-3828 Fax: (727)865-3648 Telephone: (800)488-8757 Date: 01/08/2009 Pages: 2 INCLUDING THIS COVER. If you do not receive all pages, please call (800) 488-8757.
The information contained in this facsimile message is privileged and confidential information intended only for the use of the individual or entity named above. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering it to the intended recipient, you are hereby notified that any distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone and return the original message to us at the above address by mail. Thank you.
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Ceridian COBRA Continuation Services
PARTICIPANT UPDATE Date: January 7, 2009 IMPORTANT: NOTIFY CARRIER OF THIS CHANGE IMMEDIATELY TO: JANE SAMPLE RE: CATHERINE SAMPLE CBS SALES DEMO COMPANY % JANE SAMPLE 3201 34TH ST S 3201 34TH ST S ST PETERSBURG, FL 33711 ST PETERSBURG, FL 33711
ACTION: CANCELLATION – Failure to pay premium Continuant failed to pay 12-1 premium. Grace period expired 12-31.
Last day of coverage was 11/30/08. Please notify carrier of change immediately.
Soc Sec Number : 000-00-0000 Relationship : EMP Date of Birth : 06/25/52 Election Date : 11/30/07 Employee SSN : 000-00-0000 QE Date : 10/16/07 COBRA Begin : 11/01/07 Sex : F Ben Term Date : 10/31/07 Coverage Ends : 11/30/08
CONTINUANT COVERAGE(S) *Cov Carr Type Code Carrier Name Option Status Group Number M HMO DEMO HMO A Indiv +2/Fam 001 D DENT DENTAL DEMO A Indiv +2/Fam V VIS VISION DEMO A Indiv +2/Fam
DEPENDENT COVERAGES
*Cov Start End Name SS Number DOB Sex Relation Typ Date Date SAMPLE, BARRY 000-00-0001 12/31/51 M SPO M 11/01/07 11/30/08 D 11/01/07 11/30/08 V 11/01/07 11/30/08 SAMPLE, NICHOLAS 000-00-0002 10/24/90 M SON M 11/01/07 11/30/08 D 11/01/07 11/30/08 V 11/01/07 11/30/08 SAMPLE, SARAH 000-00-0003 03/20/93 F DAU M 11/01/07 11/30/08 D 11/01/07 11/30/08 V 11/01/07 11/30/08 SAMPLE, COLLEEN 000-00-0004 03/20/93 F DAU M 11/01/07 11/30/08 D 11/01/07 11/30/08 V 11/01/07 11/30/08 * M=Medical; D=Dental; V=Vision; H=Misc; P=Prescription; O=Other; S=Same as Continuant; W= Spon Dep.; X=Class II Dep. Ceridian COBRA Continuation Services 3201 34th St. South St. Petersburg, FL 33711 800-488-8757
01/09/09 CBS SALES DEMO COMPANY Acct: WEBDEMO CERIDIAN COBRA CONTINUATION SERVICES PARTICIPANT STATUS REPORT Reporting for the period of 12/01/08 TO 12/31/08 INFORMATION ONLY NO ACTION REQUIRED Ben Notice Election QE Term Sent Period Participant’s Name: SSN Date Date Date Expires
New QE Notices Sent -----------------------------
SAMPLE, DONALD 999-00-5343 11/30/08 11/30/08 12/03/08 02/01/09 SAMPLE, ROBERT 999-00-0000 11/30/08 11/30/08 12/03/08 02/01/09
New Hire Notices Sent -------------------------------
SAMPLE, LARISSA 999-00-0060 12/17/08 SAMPLE, ROGER 999-00-8888 10/23/08 SAMPLE, JACK 999-00-3456 10/17/08 SAMPLE, LOIS 999-00-0001 10/23/08
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01/09/09 Ceridian COBRA Continuation Services
PREMIUM DISTRIBUTION REPORT AS OF: December 31, 2008
Company: CBS SALES DEMO COMPANY Account: WEBDEMO
EMPLOYEE PERIOD OF COVERAGE TYPE OF PAID TO PAID TO Participant Information: SSN NUMBER ESSN - FROM ---- TO -- COVERAGE PROVIDER CLIENT
--------------------- DENTAL DEMO --------------------- SAMPLE, MARGARET 767-67-7990 ABCD3333 761-76-6789 12/01/08 12/31/08 Dental 0.00 30.00 SAMPLE, DORIAN 999-00-0032 PDMT5465 999-00-0032 12/01/08 12/31/08 Dental 0.00 85.00 ---------------------------------------------------------------- Provider Total 0.00 115.00 Participant by status code. Count Month(s) ---------------------------------------------------------------------------------------------- Dental Employee / Individual 1 1 Dental Individual + 2 / Family 1 1 --------------------- DENTAL HMO --------------------- SAMPLE, MARGARET 767-67-7990 ABCD3333 761-76-6789 12/01/08 12/31/08 Medical 600.00 0.00 SAMPLE, DORIAN 999-00-0032 PDMT5465 999-00-0032 12/01/08 12/31/08 Medical 1200.00 0.00 ---------------------------------------------------------------- Provider Total 1800.00 0.00 Participant by status code. Count Month(s) ---------------------------------------------------------------------------------------------- Medical Employee / Individual 1 1 Medical Individual + 2 / Family 1 1 --------------------- VISION DEMO --------------------- SAMPLE, MARGARET 767-67-7990 ABCD3333 761-76-6789 12/01/08 12/31/08 Vision 0.00 15.00 SAMPLE, DORIAN 999-00-0032 PDMT5465 999-00-0032 12/01/08 12/31/08 Vision 0.00 50.00 ---------------------------------------------------------------- Provider Total 0.00 65.00 Participant by status code. Count Month(s) ---------------------------------------------------------------------------------------------- Vision Employee / Individual 1 1 Vision Individual + 2 / Family 1 1 ---------------------------------------------------------------- Unit Total 1800.00 180.00 ---------------------------------------------------------------- Division Total 1800.00 180.00 ---------------------------------------------------------------- Company Total 1800.00 180.00 Participant by status code. Count Month(s) ---------------------------------------------------------------------------------------------- Medical Employee / Individual 1 1 Dental Employee / Individual 1 1 Vision Employee / Individual 1 1 Medical Individual + 2 / Family 1 1 Dental Individual + 2 / Family 1 1 Vision Individual + 2 / Family 1 1 Total Monies Paid to Client: 180.00
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COBRA PROCEDURES MANUALOutlining the policies and procedures followed by ourorganization in the fulfillment of COBRA requirements.
This document is supplied solely for the purpose of assisting you in organizing documentationof your internal COBRA administration practices. To the extent that any of the information
contained in this document is inconsistent with IRS requirements, IRS requirements willgovern in all cases.
We suggest that you have this document reviewed by your accountant and/or attorney.
OUR COBRA ADMINISTRATION PROCEDURESOUR COBRA ADMINISTRATION SYSTEM:COBRA administration functions are performed jointly by our organization and Ceridian COBRAContinuation Services ("Ceridian"), a national COBRA compliance administrator. Within ourorganization, COBRA functions are handled by:(Internal person responsible: _____________________________________________)
Our Ceridian contact is: Client Services DepartmentCeridian COBRA Services Center3201 34th Street SouthSt. Petersburg, Florida 33711-3828Phone: 800-488-8757
Ceridian will provide all documentation related to the administrative functions it has performedon our behalf if requested in connection with an IRS audit.
OUR PROCEDURES — Initial Notification of COBRA Rights (check box that applies):
(Internal person responsible: _____________________________________________)
Each time an employee and/or spouse becomes covered under our plan, they are notified oftheir COBRA rights as follows:
Ceridian sends a General Notice of COBRA Rights, based upon the revised Department ofLabor Model Notice, via First Class Mail with proof of mailing addressed to the employee andspouse at the last known home address. If spouse resides at a different address, noticesare sent to both addresses. Proof of mailing is archived for 7 years.
We send a copy of the U.S. Department of Labor's Model General Notice of COBRA Rightsvia First Class Mail addressed to the employee and spouse at the last known home address.If spouse resides at a different address, notices are sent to both addresses. We retain acopy of this form, which includes addressee information and date sent, on file for 7 yearsfor our records.
All of our currently-covered employees and spouses have been properly provided with aGeneral Notice of COBRA Rights. We retain copies of these notices for _____ years,and store them ____________________________(location).
ContinuedCS-800/7/04QE
Please review the document, enter the appropriateinformation, and keep it for your records
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OUR PROCEDURES — COBRA Qualifying Event Notifications:
(Internal person responsible: _____________________________________________)
Each time an employee or dependent has a “Qualifying Event," we perform the followingprocedures:
1. Complete a Ceridian Qualifying Event Notification Form #CS-613 and send it to theCeridian COBRA Services Center within 14 days of the notice to the Plan Administratorof the Qualifying Event. This notice is sent to Ceridian as follows (check box thatapplies), and a copy is retained for our files:
First class mailExpress mailFAX transmissionWeb QEData transfer, via tape or disk, of Qualifying Event dataData transfer, via modem, of Qualifying Event data
2. Terminate the person from our group insurance plan. Ceridian handles all subsequentadministration related to the Qualifying Event.
(Internal person responsible: _____________________________________________)
1. Ceridian handles receipt, adjudication and processing of COBRA elections, and alsohandles all of our COBRA premium billing and collecting.
2. Ceridian sends us a Participant Status Update report each time a COBRA continuantelects and pays the first premium, a dependent is added or dropped, or a continuant iscancelled.
3. We use this report to update our carrier on COBRA continuants.
4. Once a month, Ceridian sends us a complete summary of our COBRA activity for theprevious month, together with a check for the premiums collected.
5. We check this report against our own records to verify that all proper COBRAadministrative activities have taken place. We also forward premium payments directlyto the applicable insurance carrier.
OUR PROCEDURES — Maintaining copies of standard form letters sent to qualifiedbeneficiaries regarding continuation coverage.
(Forms specified by the IRS as required for audit purposes should be attached tothis document. NOTE: Forms used by Ceridian for such communications during theperiod in which Ceridian were in effect will be provided by Ceridian when requestedat the time of audit.)
(Internal person responsible: _____________________________________________)
ContinuedCS-800/7/04QE Page 29
FORMS ATTACHED (check applicable items):Forms used prior to utilization of Ceridian administration services.
Non-Ceridian COBRA Continuation Services currently in use.
Current version of Ceridian COBRA Continuation Services forms have beenrequested (at time of audit only).
OUR INTERNAL AUDIT PROCEDURES RELATED TO COBRA:Following are the audit procedures we use to ensure that all aspects of COBRAcompliance are being properly administered. (Auditing of Ceridian-performedfunctions is accomplished by reconciling our internal COBRA records with reportsprovided by Ceridian as COBRA-related activities occur, and monthly summaryreports.)
Listed below are the COBRA administration functions, the person responsible forauditing them, the audit method, and the audit timeframe.
Function Audited by Audit Method & FrequencySending of General Notices of COBRARights to newly-covered employeesand spouses
Qualifying Event Discovery
Sending of Qualifying Event Noticesto the Ceridian COBRA Services Center
Reconciling internal records ofCOBRA activities with reports providedby CeridianAdding or deleting persons to/fromthe group health plan in response toCOBRA status communicatedby CeridianOther functions:
ContinuedCS-800/7/04QE Page 30
COPIES OF ALL GROUP HEALTH PLANS:
Accompanying this document are copies of all group health plans in force for our organization.(Check this box as complete after you have attached copies of all of your group health plans, toinclude policy, Summary Plan Description, and all amendments and riders.)
DETAILS PERTAINING TO ANY PAST REQUEST FOR CONTINUED COVERAGE AND/ORPENDING LAWSUITS RELATING TO COBRA COVERAGE:
Accompanying this document are records of past requests for continued coverage and details ofpending lawsuits (including pleadings, complaints, answers, etc.) relating to COBRA coverage.(NOTE: Ceridian keeps copies of all request letters and correspondence related to requests forcontinued coverage, and will make them available upon request at the time of audit.)
(Check this box as complete after you have attached copies of all items requested.)
MAINTENANCE OF RECORDS:
Accompanying this document is information concerning all employees who have left ouremployment during the current and 6 preceding tax years. If we cover any independentcontractors under our group health plans, a similar list for them is provided. (*NOTE: Our copiesof the Ceridian #CS-613 or #CS-913 Qualifying Event Notification Form, combined withinformation contained in the Participant Status Report sent to us monthly by Ceridian, providethe majority of information required. Ceridian will provide a list of all Qualifying Events it hasreceived notice of upon request at time of audit.(Check this box as complete after you have attached the lists requested.)
Information to include:a) Nameb) Addressc) Marital Statusd) Health plan selected, and whether such plan covered the family or just the employee.e) Dental plan selected, and whether such plan covered the family or just the employee.f) Date of termination from the company.g) Date that COBRA Continuation Coverage was made available to the terminated
employee.h) Date that COBRA Continuation Coverage was made available to the spouse and/or
dependents of the terminated employee.i) With regard to items (g) and (h), was this notice written or oral?j) With regard to items (g) and (h), was a separate notice given to each party?k) With regard to items (g) and (h), was the notice hand delivered or mailed?l) Was COBRA Continuation Coverage accepted or rejected by the employee and/or
spouse?m) Was the termination of the employee voluntary or involuntary?
