Okla. Admin. Code § 260:40-33-3

Current through Vol. 42, No. 6, December 2, 2024

Section 260:40-33-3 - COBRA administration

(a) COBRA continuation is only available to those employees and/or dependents who were covered under the plans offered by the Plan Administrator that are eligible for COBRA continuation on the date of the qualifying event or as otherwise defined in section (c) below. A leave under FMLA is not a COBRA qualifying event.

(b) New dependents may be added to coverage, including newborns, provided the employee had all eligible dependents covered at the time of the qualifying event. New dependents must be added within thirty (30) days of acquiring eligibility.

(c) A qualified beneficiary is defined as any individual who, on the day before a qualifying event, is covered under a group health plan by virtue of being on that day either a covered employee, the spouse of a covered employee, or a dependent child of a covered employee. A qualified beneficiary is also any child who is born to a covered employee or placed for adoption with a covered employee during a period of COBRA continuation coverage. A child born to or adopted by a qualified beneficiary other than the former employee is not considered a qualified beneficiary under COBRA law.

(d) If the qualifying event is termination of employment, whether voluntary or involuntary, the employing agency shall make the determination whether or not the termination was due to gross misconduct. The Plan Administrator will not make that decision, nor will it question a decision by the employing agency on this issue. If a decision is made by the agency that the employee was terminated due to gross misconduct, the COBRA form should clearly specify that fact.

(e) Once election to continue coverage has been made, coverage will terminate in eighteen (18) months if the qualifying event is termination or reduction in hours, or thirty-six (36) months if the qualifying event is death, divorce or legal separation, or ceasing to be a dependent child. Coverage may also terminate if the Plan Administrator ceases to offer any plans eligible for COBRA continuation, or if the beneficiary fails to make timely payments of any premiums required, or if the beneficiary becomes covered under any other group plan unless the new group plan contains an exclusion or limitation with respect to any pre-existing condition of the participant.

(1) The maximum eligibility period may be extended to twenty-nine (29) 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 or before the COBRA event date or within the first sixty (60) days following the start of continuation coverage. The qualified beneficiary must provide the employer or designated COBRA administrator with a copy of the Social Security determination notice within 60 days after the determination is issued and before the end of the initial eighteen (18) months of COBRA.

(2) If the Social Security Administration reevaluates the participant's case and determines that the participant is no longer disabled, the participant must provide the agency or the designated COBRA administrator with a copy of the determination notice. This copy must be sent within thirty (30) days. Coverage will end at the end of the month that begins more that thirty (30) days after the date of the final determination. For example, if a final determination notice date is May 15, coverage would end June 30.

(3) If an employee is receiving Medicare prior to retirement or another COBRA event, he/she can continue COBRA coverage for eighteen months (18) after the retirement or other qualifying COBRA event. However, the spouse and or other qualified beneficiaries shall be allowed to have COBRA for thirty-six (36) months after the Medicare entitlement date.

(f) No evidence of insurability shall be required for continuation of coverage.

(g) The coverage elected shall be identical to the coverage provided at the date of the qualifying event, unless a beneficiary moves outside an HMO's service area. In that event, coverage is continued under the plan offered by the EGID.

(h) Each covered beneficiary has the same rights and benefits as any similarly situated person to whom a qualifying event has not occurred. There are the same limitations and exclusions, except to the extent to which it would conflict with federal law.

(i) Any election of a qualified beneficiary shall be deemed to include an election of continuation on behalf of all other qualified beneficiaries residing together, unless specified in the election.

(j) Applicable premiums shall be determined on an actuarial basis for a twelve (12) month period, on or before the start of the Plan Year each year. The premiums shall remain the same during the Plan Year.

(k) All back premiums from the termination of coverage to the election and approval of continuation must be paid before coverage is effective. Coverage will then be retroactive to provide continuous coverage. All time limits are mandatory and cannot be waived under any circumstances.

(l) If a qualified beneficiary waives continuation of coverage, he/she may revoke that waiver anytime within the 60 day election period, but no claims are payable nor will any coverage be applied to the period prior to the revocation of the waiver.

(m) It is the responsibility of the qualified beneficiary to notify the Plan Administrator if he or she is not eligible for any reason. Failure to do so will result in cancellation of COBRA insurance coverage retroactive to the time of ineligibility.

(n) The date of the qualifying event shall be the same date as the actual loss of coverage under the previous plan. The period of continuation coverage and the applicable notification periods shall begin on the date of the actual loss of other coverage. The Plan Administrator shall have the right to make a final determination as to when the actual date of termination occurred.

Okla. Admin. Code § 260:40-33-3

Adopted by Oklahoma Register, Volume 31, Issue 24, September 2, 2014, eff. 9/12/2014