Ceridian COBRA Continuation Services

Transcription

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
II
III
IV.
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
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
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
Frequently Asked Questions
15
A. [NOTICE ISSUES] How will I know if there are problems
once I enter a COBRA event through the Web?
15
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
my COBRA account?
16
F. [CLIENT BILLING] How am I billed for these services?
16
Page 1
V
VI
VII
G. [DISHONORED CHECKS] How are bad checks handled?
16
H. [CAL-COBRA] What is Cal-COBRA, and can Ceridian assist
with that administration?
17
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?
17
J.
[CLIENT FEES-SURCHARGE] In my sales contract there is
reference to a surcharge. What is that?
17
K. [ELIGIBILITY REPORTING] Can Ceridian notify my
carrier/insurer of changes to my COBRA participants?
17
L. [SHORT PAYMENTS] What is Safe Harbor?
18
M. [NOTICE TIMEFRAMES] What are the timeframes to submit
COBRA (Qualifying event and New Hire/Initial/General notices)
events to Ceridian?
18
N. [PRORATING PREMIUMS] My employees' benefits end on
their last day of work, but I want everyone on the same billing
cycle, how can this work?
18
O. [CLIENT FEES] Can the monthly COBRA fee be taken from
the COBRA participant's premiums?
18
P. [CERIDIAN CONTACTS] Who should clients contact at Ceridian?
19
Notification Forms
A. Takeover Form
20
B. Qualifying Event Form
21
C.
22
New Hire Notification Form
Sample Reports
A. Participant Update Sample Report
23, 24
B. Participant Status Sample Report
25, 26
C. Premium Distribution Sample Report
27
COBRA Procedures Manual
28 - 31
Page 2
Welcome to Ceridian COBRA Continuation Services
Dear Ceridian COBRA Continuation Services Customer:
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
Page 3
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 60day 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.
Additional Services
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.
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What the Employer Does
Notifications
If 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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COBRA Compliance Requirements
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 FirstClass 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
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.
Page 6
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 18or 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.
Ceridian COBRA Process
I.
Qualifying Events
1. 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.
Page 7
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 enhancedservices@ceridian.com 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.
Page 8
Ceridian Web Capabilities
Ceridian 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 general
information, 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.
Page 9
Web Access for Employers
Ceridian’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:
Page 10
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:
Page 11
Employers can also search for participant information individually using many different
parameters. A sample screen shot is below:
Page 12
WebQE COBRA Procedures
It 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.
Page 13
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 1-800469-0429 or email us at webqe@ceridian.com.
Technical Web Support
Ceridian Corporation
3201 34th Street South
St. Petersburg, FL 33711
Page 14
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.
Page 15
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
Page 16
to the client and/or insurer.
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.
Page 17
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.
Page 18
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
enhancedservices@ceridian.com.
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 Webqe@ceridian.com
Who should COBRA participants or eligible employees contact for assistance?
Participant Customer Service can be contacted by email at cobracustomerservice@ceridian.com
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.
Page 19
COBRA Continuant Takeover Form
CS-614SUB/1/06
(For transferring current COBRA continuants to Ceridian)
PLEASE CHECK
ONE BOX D
ORIGINAL NOTICE If FAXED, do not mail copy.
REVISION . . . to a form that was previously sent.
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 33747-4066
Telephone: 800-488-8757 • Fax: 727-865-3648
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 or two
characters required [alpha and/or numeric] to complete 1b and 1c above.)
2) Ceridian COBRA Services Account # (indicated on the Client Rate report for location or
subsidiary)
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)
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)
Death of covered employee /retiree (Code 3)
Divorce/legal separation (Code 4)
Covered employee/retiree becomes
entitled to Medicare; dependents
may elect continuance of identical
coverage (Code 5)
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 Code
and Plan Code for each coverage elected.
Carrier Code
Option Code
Plan Code*
Med or HMO _______________
_______________
_______________
Dental
_______________
_______________
_______________
Vision
_______________
_______________
_______________
Hearing
_______________
_______________
_______________
Prescription _______________
_______________
_______________
Other
_______________
_______________
_______________
* Select from the following current Plan Code coverages — Ceridian administers
Plan only Code coverage options that are permitted by your plan or carrier:
1 = Individual
3 = Family
14 = Individual + Child
2 = 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
5b) Street (include apartment number)
19) Subsidy Applies? (check one)
Subsidy Begin Date:
5c) City
Subsidy End Date:
5d) State
5e) Zip Code
-- 7) Employee Number (if applicable)
M
M
D
D
Y
Y
Y
10) Marital Status (check one)
(S)ingle
(M)arried
9) Gender (check one)
(M)ale
(F)emale
Y
(W)idowed
(D)ivorced
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
M
M
D
D
Y
Y
Y
Y
13) Last day of pre-COBRA Coverage (cannot be prior to Qualifying Event Date)
M
M
D
D
Y
Y
Y
Y
14) First premium due-date for which Ceridian is to bill.
M
M
D
D
Y
Y
Y
Y
(N)o
(Y)es
M
M
D
D
Y
Y
Y
Y
M
M
D
D
Y
Y
Y
Y
20) If the COBRA Continuant has dependent(s) covered, please complete the section
below (please provide last, first and middle initial for the name):
6) Home Phone # (if available)
8) Date of Birth
Ineligibility of dependent child (Code 6)
Retiree,
spouse
retiree loses
F Retiree,
spouseor
or child
child ofof retiree
loses coverage
withinyear
one year
before
coverage
within one
before
or after
or after commencement of proceedings
commencement
of
proceedings
by sponsoring employer under Title by
11
(Code
sponsoring
employer
underCode
Title
117)
(bankruptcy)
United States
Dependent Name ______________________________________________________
Social Security Number______________ —__________—_______________
Date of Birth (month/day/year) ________________________________________
Gender
(M)ale
(F)emale
Relationship to employee ________________________________________________
Covered under group health plan on day of Qualifying Event? (check one) (Y)es (N)o
Dependent Name ______________________________________________________
Social Security Number ______________ —__________—_______________
Gender
(M)ale
(F)emale
Relationship to employee _________________________________________________
Covered under group health plan on day of Qualifying Event? (check one)
(Y)es (N)o
Dependent Name ______________________________________________________
Social Security Number ______________ —__________—_______________
Gender
(M)ale
(F)emale
Relationship to employee _________________________________________________
Covered under group health plan on day of Qualifying Event? (check one) (Y)es (N)o
Prepared By:
Name: (Print)
Date:
Phone #:
Fax #:
-- -- M
M
D
D
Y
Y
Y
Y
Ceridian COBRA Services Center • 3201 34th Street South • St. Petersburg, Florida 33711-3828 • 800-488-8757 • Fax: 727-865-3648
Page 20 © 2006 Ceridian Corporation
Page 20
CS-613/7/04
COBRA QUALIFYING EVENT
PLEASE CHECK ORIGINAL NOTICE If FAXED, do not mail copy.
ONE BOX D
REVISION . . . to a form that was previously sent.
16) COBRA Qualifying Event that caused loss of coverage (check one)
Employee’s retirement (Code 8)
Employee’s reduction in hours (Code 2)
(Code 1)
Employee’s resignation
Employee’s layoff (Code 0)
(Code C)
Employee’s involuntary termination
Employee’s begins leave of absence (Code 9)
1a) From (Company)
1b) Division or Region Code
1c) Company ID or Unit Code
Divorce/legal separation (Code 4)
Ineligibility of dependent child (Code 6)
Covered employee/retiree becomes
entitled to Medicare; dependents
may elect continuance
of coverage(Code 5
(If applicable, refer to the Client Rate Report for the one character to two
characters 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)
(E)mployee
(D)ependent
4) Social Security Number of Qualified Beneficiary
-- Death of covered employee /retiree (Code 3)
Retiree, spouse or child of retiree loses
coverage within one year before or
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, first
and middle initial.
Name of Spouse____________________________________________
-- Social Security Number
5a) Qualified Beneficiary’s Name (last, first, mi)
Date of Birth
M
M
D
D
Male Female
Y
Y
Y
Y
5b) Street (include apartment number)
Gender
5c) City
Address (if different from participant) ______________________________
_________________________________________________________________________
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
5d) State
5e) Zip Code
○
○
Name of Dependent_________________________________________
6) Home Phone # of Qualified Beneficiary (include Area Code) 7) Employee # (if applicable)
-- 8) Date of Birth of Qualified Beneficiary
M
M
D
D
Y
Y
Y
Employee SSN
Date of Birth
(F)emale
10) If the Qualified Beneficiary listed in box #5a is not the employee, enter
the following:
Employee Name (last, first, mi)_________________________________________
M
○
○
-- D
Y
Y
Y
M
D
D
Y
Y
Y
Y
Y
○
-- M
Y
Y
M
D
D
Y
Y
Y
Y
Male Female
Gender
○
(N)o (Y)es
○
_________________________________________________________________________
○
○
○
○
○
○
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
Name of Dependent_________________________________________
14) If employee, does he/she have a health care FSA?
(N)o (Y)es
Y
_________________________________________________________________________
○
○
○
○
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
Date of Birth
13) Is this a second Qualifying Event for a dependent who is currently
on COBRA?
Y
Social Security Number
12) Last day of pre-COBRA Coverage (cannot be prior to Qualifying Event Date)
M
D
Name of Dependent___________________________________________
D
D
11) Qualifying Event Date
M
M
Male Female
Gender
Dependent’s Relationship to Employee _____________________________
M
9) Gender (check one)
(M)ale
Y
○
(If yes, MONTHLY contribution $_____________________)
15) Refer to your Client Rate Report and enter the current Carrier Option, Option
Code and Plan Code for each coverage in effect on the Qualifying Event Date:
Carrier Code
Option Code
Plan Code*
Med or HMO _______________
_______________
_______________
Dental
_______________
_______________
_______________
Vision
_______________
_______________
_______________
Hearing
_______________
_______________
_______________
Prescription _______________
_______________
_______________
Other
_______________
_______________
_______________
*Select from the following current Plan Code Coverages. Ceridian administers only
Plan Code coverage options that are permitted by your plan or carrier:
1 = Individual
3 = Family
14 = Individual+Child
2 = Individual + 1
9 = Individual + Spouse
15 = Individual + Children
Date of Birth
M
M
D
D
Y
Y
Y
Y
Male Female
Gender
Address (if different from participant) ________________________________
Please see Addendum if additional names need to be listed in this section
Prepared By
Name: (PRINT)________________________________________________
Date:
Telephone #
Fax #
-- -- M
M
D
D
Y
Y
Y
Y
Ceridian COBRA Services Center • 3201 34th Street South • St. Petersburg, Florida 33711-3828 • 800-488-8757 • Fax 727-865-3648
Page 21 © 2004 Ceridian Corporation
○
CS-611/7/04QE
NEW EMPLOYEE/COVERED SPOUSE
NOTIFICATION FORM
From: ___________________________________________________
Company
________________________________________________________
Ceridian COBRA Services Center
P. O. Box 534066
St. Petersburg, Florida 33747-4066
Division or Region Code
Company ID or Unit Code
Ceridian COBRA Services Account #: ______________________
Please notify the following new employee and/or new spouse of his/her COBRA continuation
rights:
o new employee
o newly covered spouse
If an active covered employee who has been notified previously by Ceridian is adding a spouse to the
plan, check here: o
Employee SSN#_________________________________________
Name of
Employee:
__________________________________________________
Last
First
MI
____________
Gender
Mailing Address: ____________________________________________________________
Street
City
Name of Spouse: ______________________________
State
Zip
__________________________
Last
First
Note: This employee has dependent(s) who live at the following different address(es):
Name:_________________________________
Relationship:_________________________
Mailing Address: ____________________________________________________________
Street
City
State
Zip
Name:__________________________________ Relationship:________________________
Mailing Address: ____________________________________________________________
Street
City
State
Zip
Prepared by:_________________________________________________________________
Name and Title (please print)
________________________________________
Signature
_______________
Date
____________________
Phone #
____________________
Fax #
Ceridian COBRA Services Center • 3201 34th Street South • St. Petersburg, Florida 33711-3828
Telephone: 800-488-8757 • Fax: 727-865-3648
Page 22
SAMPLE - Participant Update Report Fax
Facsimile Cover Sheet
To:
Fax No:
JANE SAMPLE, CBS SALES DEMO COMPANY
727-555-1212, Voice No: 727-555-1212
From:
Date:
Pages:
St. Petersburg, FL 33711-3828
Fax: (727)865-3648
Telephone: (800)488-8757
01/08/2009
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.
Page 23
PARTICIPANT UPDATE
Date: January 7, 2009
IMPORTANT:
NOTIFY CARRIER OF THIS CHANGE IMMEDIATELY
RE: CATHERINE SAMPLE
% JANE SAMPLE
3201 34TH ST S
ST PETERSBURG, FL 33711
TO: JANE SAMPLE
CBS SALES DEMO COMPANY
3201 34TH ST S
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
Relationship
Employee SSN
Sex
:
:
:
:
000-00-0000
EMP
000-00-0000
F
Date of Birth
:
QE Date
:
Ben Term Date :
06/25/52
10/16/07
10/31/07
Election Date
COBRA Begin
Coverage Ends
:
:
:
11/30/07
11/01/07
11/30/08
CONTINUANT COVERAGE(S)
*Cov
Type
M
D
V
Carr
Code
HMO
DENT
VIS
Carrier Name
DEMO HMO
DENTAL DEMO
VISION DEMO
Option
A
A
A
Status
Indiv +2/Fam
Indiv +2/Fam
Indiv +2/Fam
Group Number
001
DEPENDENT COVERAGES
Name
SAMPLE, BARRY
SS Number
000-00-0001
DOB
Sex
12/31/51 M
Relation
SPO
SAMPLE, NICHOLAS
000-00-0002
10/24/90 M
SON
SAMPLE, SARAH
000-00-0003
03/20/93 F
DAU
SAMPLE, COLLEEN
000-00-0004
03/20/93 F
DAU
* M=Medical; D=Dental;
V=Vision;
W= Spon Dep.;
X=Class II Dep.
H=Misc;
P=Prescription;
th
3201 34 St. South
Page 24
O=Other;
*Cov
Typ
M
D
V
M
D
V
M
D
V
M
D
V
Start
Date
11/01/07
11/01/07
11/01/07
11/01/07
11/01/07
11/01/07
11/01/07
11/01/07
11/01/07
11/01/07
11/01/07
11/01/07
End
Date
11/30/08
11/30/08
11/30/08
11/30/08
11/30/08
11/30/08
11/30/08
11/30/08
11/30/08
11/30/08
11/30/08
11/30/08
S=Same as Continuant;
St. Petersburg, FL 33711
800-488-8757
01/09/09
VISION DEMO (VIS)
999-00-0032
Acct: WEBDEMO
Reporting for the period of
12/01/08 TO 12/31/08
CERIDIAN COBRA CONTINUATION SERVICES PARTICIPANT STATUS REPORT
999-00-0032
761-76-6789
04/12/67
06/21/57
Employee # PDMT5465
--- SSN ---D.O.B.
SEX
999-00-0033
04/24/66
M
999-00-0034
04/24/97
F
767-67-7990
000-00-0000
06/25/52
Employee # ABCD3333
000-00-0000
Employee # PDMT2323
--- SSN ---D.O.B.
SEX
000-00-0001
12/23/51
M
000-00-0002
10/24/90
M
000-00-0003
03/20/93
F
000-00-0004
05/04/92
F
F
RELT
SPO
DAU
F
F
RELT
SPO
SON
DAU
DAU
EMP
SPO
EMP
V
ENDING
A
A
VISION
11/01/08
11/01/08
V
ENDING
11/30/08
11/30/08
11/30/08
11/30/08
A
VISION
11/01/07
11/01/07
11/01/07
11/01/07
V
ACTION REQUIRED SECTION
3
1
10/16/08 10/31/08 11/01/08
04/16/10 12/31/08
04/16/09 11/30/08 12/31/08
08/11/11 12/31/08
10/16/07 10/31/07 11/01/07
08/11/08 08/31/08 09/01/08
1
3
3
1
BEN
COBRA
COBRA
DATE
COVG BEN
FAM
QE
TERM
ELIG
ELIG
PAID
GRACE
PARTICIPANT’S NAME:
SSN
ESSN
OF BIRTH
SEX RELT TYPE CLASS OPT STAT QE DATE
DATE STARTS
ENDS
THRU ENDING
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Active Billings
------------------SAMPLE, DORIAN
% JANE SAMPLE
3201 34TH ST S
--- DEPENDENT’S NAME
SAMPLE, THOMAS
SAMPLE, KAREN
SAMPLE, MARGARET
% JANE SAMPLE
TH
3201 34 ST S
Cancellations
-----------------SAMPLE, CATHERINE
% JANE SAMPLE
TH
3201 34 ST S
--- DEPENDENT’S NAME
SAMPLE, BARRY
SAMPLE, NICHOLAS
SAMPLE, SARAH
SAMPLE, COLLEEN
Page 25
01/09/09
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
SSN
QE
Date
Ben
Term
Date
Notice
Sent
Date
Election
Period
Expires
New QE Notices Sent
----------------------------SAMPLE, DONALD
SAMPLE, ROBERT
999-00-5343
999-00-0000
11/30/08
11/30/08
11/30/08
11/30/08
12/03/08
12/03/08
02/01/09
02/01/09
Waiting for Election
-------------------------SAMPLE, DOLORES
SAMPLE, JANET
SAMPLE, CHRISTINE
999-00-7894
999-00-7789
999-00-0061
12/31/08
11/30/08
11/12/08
12/31/08
11/30/08
11/30/08
11/28/08
11/26/08
11/13/08
03/01/09
01/29/09
01/29/09
COBRA Rights Expired
------------------------------SAMPLE, CARL
SAMPLE, DAVID
SAMPLE, JOHN
SAMPLE, LAURIE
SAMPLE, LOGAN
999-00-0060
999-00-7720
999-00-0023
999-00-7750
999-00-7730
10/20/08
10/05/08
09/17/08
10/01/08
10/16/08
10/31/08
10/31/08
09/30/08
10/31/08
10/31/08
10/27/08
10/23/08
10/17/08
10/23/08
10/24/08
12/30/08
12/30/08
12/16/08
12/30/08
12/30/08
New Hire Notices Sent
------------------------------SAMPLE, LARISSA
SAMPLE, ROGER
SAMPLE, JACK
SAMPLE, LOIS
999-00-0060
999-00-8888
999-00-3456
999-00-0001
Participant’s Name:
12/17/08
10/23/08
10/17/08
10/23/08
Page 26
01/09/09
PREMIUM DISTRIBUTION REPORT AS OF: December 31, 2008
Company: CBS SALES DEMO COMPANY
Participant Information:
--------------------DENTAL DEMO
--------------------SAMPLE, MARGARET
SAMPLE, DORIAN
SSN
EMPLOYEE
NUMBER
ESSN
767-67-7990
999-00-0032
ABCD3333
PDMT5465
761-76-6789
999-00-0032
Account: WEBDEMO
PERIOD OF COVERAGE
- FROM ---- TO --
12/01/08
12/01/08
12/31/08
12/31/08
TYPE OF
COVERAGE
PAID TO
PROVIDER
PAID TO
CLIENT
Dental
0.00
30.00
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
SAMPLE, DORIAN
767-67-7990
999-00-0032
ABCD3333
PDMT5465
761-76-6789
999-00-0032
12/01/08
12/01/08
12/31/08
12/31/08
Medical
600.00
0.00
Medical
1200.00
0.00
---------------------------------------------------------------Provider Total
1800.00
0.00
Count
Month(s)
---------------------------------------------------------------------------------------------Medical Employee / Individual
1
1
Medical Individual + 2 / Family
1
1
--------------------VISION DEMO
--------------------SAMPLE, MARGARET
SAMPLE, DORIAN
767-67-7990
999-00-0032
ABCD3333
PDMT5465
761-76-6789
999-00-0032
12/01/08
12/01/08
12/31/08
12/31/08
Vision
0.00
15.00
Vision
0.00
50.00
---------------------------------------------------------------Provider Total
0.00
65.00
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
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:
Page 27
180.00
COBRA PROCEDURES MANUAL
Outlining the policies and procedures followed by our
organization in the fulfillment of COBRA requirements.
This document is supplied solely for the purpose of assisting you in organizing documentation
of your internal COBRA administration practices. To the extent that any of the information
contained in this document is inconsistent with IRS requirements, IRS requirements will
govern in all cases.
We suggest that you have this document reviewed by your accountant and/or attorney.
Please review the document, enter the appropriate
information, and keep it for your records
OUR COBRA ADMINISTRATION PROCEDURES
OUR COBRA ADMINISTRATION SYSTEM:
COBRA administration functions are performed jointly by our organization and Ceridian COBRA
Continuation Services ("Ceridian"), a national COBRA compliance administrator. Within our
organization, COBRA functions are handled by:
(Internal person responsible: _____________________________________________)
O ur Ceridian contact is:
Client Services Department
Ceridian COBRA Services Center
St. Petersburg, Florida 33711-3828
Phone: 800-488-8757
Ceridian will provide all documentation related to the administrative functions it has performed
on our behalf if requested in connection with an IRS audit.
OUR PROCEDURES — Initial Notification of COBRA Rights (check box that applies):
Each time an employee and/or spouse becomes covered under our plan, they are notified of
their COBRA rights as follows:

Ceridian sends a General Notice of COBRA Rights, based upon the revised Department of
Labor Model Notice, via First Class Mail with proof of mailing 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. 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 Rights
via 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 a
copy of this form, which includes addressee information and date sent, on file for 7 years
for our records.

All of our currently-covered employees and spouses have been properly provided with a
General Notice of COBRA Rights. We retain copies of these notices for _____ years,
and store them ____________________________(location).
CS-800/7/04QE
Page 28
Continued
OUR PROCEDURES — COBRA Qualifying Event Notifications:
Each time an employee or dependent has a “Qualifying Event," we perform the following
procedures:
1.
Complete a Ceridian Qualifying Event Notification Form #CS-613 and send it to the
Ceridian COBRA Services Center within 14 days of the notice to the Plan Administrator
of the Qualifying Event. This notice is sent to Ceridian as follows (check box that
applies), and a copy is retained for our files:
First class mail
Express mail
FAX transmission
Web QE
Data transfer, via tape or disk, of Qualifying Event data
Data transfer, via modem, of Qualifying Event data
2.
Terminate the person from our group insurance plan. Ceridian handles all subsequent
administration related to the Qualifying Event.
OUR PROCEDURES — Billing/Collecting/Ongoing Eligibility Adjudication:
1.
Ceridian handles receipt, adjudication and processing of COBRA elections, and also
handles all of our COBRA premium billing and collecting.
2.
Ceridian sends us a Participant Status Update report each time a COBRA continuant
elects and pays the first premium, a dependent is added or dropped, or a continuant is
cancelled.
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 the
previous month, together with a check for the premiums collected.
5.
We check this report against our own records to verify that all proper COBRA
administrative activities have taken place. We also forward premium payments directly
to the applicable insurance carrier.
OUR PROCEDURES — Maintaining copies of standard form letters sent to qualified
beneficiaries regarding continuation coverage.
(Forms specified by the IRS as required for audit purposes should be attached to
this document. NOTE: Forms used by Ceridian for such communications during the
period in which Ceridian were in effect will be provided by Ceridian when requested
at the time of audit.)
CS-800/7/04QE
Page 29
Continued
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 been
requested (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 COBRA
compliance are being properly administered. (Auditing of Ceridian-performed
functions is accomplished by reconciling our internal COBRA records with reports
provided by Ceridian as COBRA-related activities occur, and monthly summary
reports.)
Listed below are the COBRA administration functions, the person responsible for
auditing them, the audit method, and the audit timeframe.
Function
Audited by
Audit Method & Frequency
Sending of General Notices of COBRA
Rights to newly-covered employees
and spouses
Qualifying Event Discovery
Sending of Qualifying Event Notices
to the Ceridian COBRA Services Center
Reconciling internal records of
COBRA activities with reports provided
by Ceridian
Adding or deleting persons to/from
the group health plan in response to
COBRA status communicated
by Ceridian
Other functions:
CS-800/7/04QE
Page 30
Continued
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, to
include policy, Summary Plan Description, and all amendments and riders.)
DETAILS PERTAINING TO ANY PAST REQUEST FOR CONTINUED COVERAGE AND/OR
PENDING LAWSUITS RELATING TO COBRA COVERAGE:

Accompanying this document are records of past requests for continued coverage and details of
pending lawsuits (including pleadings, complaints, answers, etc.) relating to COBRA coverage.
(NOTE: Ceridian keeps copies of all request letters and correspondence related to requests for
continued 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 our
employment during the current and 6 preceding tax years. If we cover any independent
contractors under our group health plans, a similar list for them is provided. (*NOTE: Our copies
of the Ceridian #CS-613 or #CS-913 Qualifying Event Notification Form, combined with
information contained in the Participant Status Report sent to us monthly by Ceridian, provide
the majority of information required. Ceridian will provide a list of all Qualifying Events it has
received notice of upon request at time of audit.
(Check this box as complete after you have attached the lists requested.)
Information to include:
a) Name
b) Address
c) Marital Status
d) 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?
Ceridian COBRA Services Center • 3201 34th Street South • St. Petersburg, Florida 33711-3648 • 800-488-8757
CS-800/7/04QE
Page 31
© 2004 Ceridian Coporation