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Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986

Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986

Welcome to the School District of Philadelphia's COBRA page!

Please click on the links below for more information on how this program works:

General Information

 

COBRA is an acronym for Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986. 

COBRA provides certain former employees, retirees, spouses, former spouses, and dependent children the right to temporary continuation of health coverage at group rates. This coverage, however, is only available when coverage is lost due to certain specific events. Group health coverage for COBRA participants is typically more expensive than health coverage for active employees, since the employer ususally pays a part of the premium for active employees. COBRA participants generally pay the entire premium themselves, however, it is ordinarily less expensive, though, than individual health coverage.

Several events that can cause employees and their family members to lose group health coverage may result in the right to COBRA coverage. These include:

  • Voluntary or involuntary termination of the covered employee’s employment for reasons other than gross misconduct.
  • Reduced hours of work for the covered employee.
  • Divorce or legal separation of a covered employee.
  • Death of a covered employee
  • Loss of status as a dependent child under plan rules.

Under COBRA, the employee or family member may qualify to keep their group health plan benefits for a set period of time, depending on the reason for losing the health coverage.

Qualified Beneficiary

Qualifying Event

Period of Coverage

Employee
*Spouse
Dependent child

Termination
Reduced hours

18 months

Spouse
Dependent child

Divorce or legal separation
Death of covered employee

36 months

Dependent child

Loss of dependent child status

36 months

* This 18-month period may be extended for all qualified beneficiaries if certain conditions are met in cases where a qualified beneficiary is determined to be disabled for purposes of COBRA. However, COBRA also provides that continuation coverage may be cut short in certain cases.

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Other Important Information: 

PA Acts 110/43 

Two acts of the Pennsylvania State Legislature go beyond COBRA to provide additional coverage opportunities for eligible retired school employees.  Commonly referred to as PA Acts 110/43.  Act 110 (1988) requires school employers in Pennsylvania to give retirees and their dependents the right to continue coverage in the group health plan to which they belonged as employees.  The coverage may continue until they are eligible for Medicare benefits (usually age 65) or until they are covered by another group health insurance plan.  Act 43 (1989) amended Act 110 by defining those retirees eligible for continuation of group coverage as those who:

  • took superannuation retirement on or after age 62,
  • retired with thirty (30) years of service, OR
  • were receiving PSERS disability benefits

Most, but not all, retirees find it advantageous to continue in their former employer plans until they become eligible for Medicare.  Your eligibility for this coverage ends when you begin to receive Medicare benefits unless you happen to still be employed.  See Retiree Medicare Options for coverage at age 65.

Employees, who resign, are terminated or retire and are NOT eligible for PA Acts 110/43, are offered COBRA for 18 months.  Once they leave our COBRA group, they cannot return.

If an employee is eligible under PA Acts 110/43, they and their spouse may continue in the SDPs under 65 medical plan (COBRA) to which they were entitled as an employee, until they are Medicare eligible.

Dependent children are entitled to a minimum of 36 months of coverage as defined by COBRA.  There is no entitlement granted to dependent children by acts 110/43, however, children, up to age 26, may remain on the policy as long as the insured or spouse is covered. 

Employees have the choice not to elect coverage upon retirement and may elect it at a later time under certain circumstances. If an employee is covered under another employer group and experiences a qualifying event (such as loss of coverage), they may elect to enroll in the SDPs group, with no break in coverage from their former coverage. The employee must provide documentation to the SDP within 60 of the Qualifying Event. Qualifying Events are explained below.

To request return to the Retiree Group, mail or fax the following documentation and confirm receipt by contacting us at 215-400-4630:

Employee Benefits - Retiree Coverage
440 N. Broad Street
Suite G10
Philadelphia, PA 19130
Fax: 215-400-4631
  • Provide Certificate of Group Health coverage or Employer letter documenting continuous group coverage since termination of SDP coverage or material change for employee and eligible dependents.
  • Provide proof of loss of coverage for employee and eligible dependents or
  • Provide current mailing address with phone number, and demographic information for any dependents to be covered. This includes full name, Date of birth and social security number.

The School District will confirm your Act 110/43 eligibility with PSERS.  Election materials will be mailed by AmeriHealth Administrators.  We make every attempt to expedite requests; however it may take up to 15 working days for your election materials to be mailed to you.

According to section 102 of the Employee Retirement Income Security Act of 1974 (ERISA), a material modification includes:

  • Any coverage modification that alone or combined with other changes made at the same time would be considered by "an average participant" to be "an important change in covered benefits or other terms of coverage under the plan or policy."
  • An enhancement of covered benefits, services or other more general, plan or policy terms. For example, coverage of previously excluded benefits or reduced cost-sharing.
  • A "material reduction in covered services or benefits" or more strict requirements for "receipt of benefits," including:
  • Changes or modifications that reduce or eliminate benefits
  • Increases in cost-sharing
  • Imposing a new referral requirement

 

 

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Disability

Generally, the maximum period of COBRA continuation coverage is 18 months.

If you are granted a Public School Employees' Retirement System (PSERS) Disability Retirement, you are entitled to continuation under PA Acts 110/43.  Contact the Employee Benefits office at (215) 400-4630 for more information. 

If you do not have a PSERS Disability, but you or a family member becomes disabled at any time either before becoming eligible for COBRA continuation coverage or within the first 60 days of being covered by COBRA continuation coverage, .all of the qualified beneficiaries in that family are entitled to an 11-month extension of an 18-month COBRA coverage period (for a total maximum period of 29 months of COBRA coverage). This disability extension will apply to the all family members who are receiving COBRA continuation coverage due to the same qualifying event as the person disabled.

 

In order to qualify for the disability extension to COBRA continuation coverage, the Social Security Administration must find you or an enrolled family member were disabled at some point prior to, or during the first 60 days of COBRA continuation coverage. Therefore, if you believe you may qualify for the disability extension, it is important to contact the SSA and apply for disability benefits under the Social Security act. In addition, you must notify AmeriHealth Administrators of the SSA determination of your disability before you are entitled to the disability extension.

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Alternatives to COBRA

If you do not want to continue the Ditrict's coverage through COBRA, you may be able to enroll in other medical insurance programs, however, you will need to do some research and comparison shopping.  Make sure that you do not have a lapse in coverage.  You may want to enroll in COBRA while you research other options.  Here are some tips and suggestions:

 


The Affordable Health Care Act Market Place

The Affordable Care Act created the Health Care Exchange.  If you expereince a loss in coverage, call them at 1-800-318-2596 or visit the exchange at  www.healthcare.gov

 

Do you have coverage available through a spouse or other employer? You may have coverage available through a second job or your spouse's employer.  Typically if you notify them of your loss of coverage within 30 days, you may enroll in their plan at that time.  Check with the employer's Human Resources or Benefits department.   If they require proof of loss of coverage, contact Independence Blue Cross at 1-800-ASK-BLUE to request a HIPAA Certification of Coverage.

Are you or a spouse age 65 or over, or eligible for Medicare due to a disability? Contact Social Security at (800) 772-1213 or www.socialsecurity.gov about enrolling in Medicare Part B. If they require a Request for Employment Information form, contact the Employee Benefits Office (215) 400-4630 to have this completed. If you are Medicare eligible and begin collecting your pension, you may enroll in Medicare plans through PSERS Health Options Program (800) 773-7725. Information on individual Medicare plans is available at https://www.medicare.gov/.

Are your children under age 19? If you live in Pennsylvania, CHIP covers all uninsured kids and teens up to age 19 that are not eligible for Medical Assistance. When your child loses health benefits because of your job loss, the six month waiting period is waived.   For more information see the PA Covers Kids or in New Jersey contact NJ Family Care.

Do you or someone in your family qualify for Medicaid?  In general, you must meet specific medical eligibility requirements, and/or age and be financially needy.  You can find out if you qualify for and apply for Pennsylvania Health and Human services benefits on their website site, COMPASS.  You can apply at any time during the day or night from home, a library or any location with Internet access.  Or you visit your local County Assistance Office. 

Are there non-group plans available?  You may want to contact an insurance broker or call insurance companies directly to find out what plans are available.  If you meet the underwriting requirements, rates will typically be much lower than COBRA for younger subscribers. 

What if I am not in excellent health?  If you do not have a break in coverage, you may be able to enroll in a HIPAA Continued Coverage plan or conversion plans directly through Independence Blue Cross.  Contact them at 1-800-ASK-BLUE (1-800-275-2583) for information.

Does everyone in my family need to elect the same coverage?  Everyone who elects COBRA must elect the same plan.  However, you may find that a combination of some family members electing COBRA and others getting individual plans may provide the best coverage for your needs.  When requesting quotes for coverage, get rates based on each individual as well as for your whole family.  

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Open Enrollment

Open Enrollment for Self Pay Continuants (COBRA and Retiree) is in May.  Changes are effective July 1. Letters are mailed to current subscribers's homes.  The contact phone number for AmeriHealth Administrators is 1-888-547-5090.

Please click here for information on Open Enrollment for Continuants, COBRA and Retirees.  

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Who's eligible for this benefit?

When you are hired, you receive an initial notice for you and your covered dependents, informing you and your eligible dependents (i.e., spouse, domestic partner, and children) of your rights under COBRA and describing provisions of the law. 

To be eligible for COBRA coverage, the qualified beneficiary must have been enrolled in our group health plan while you were enrolled in the District's group coverage as an eligible employee.

If a couple can demonstrate that at one time, both were employees of the SDP, they may elect to enroll in 2 single policies; otherwise, they must enroll as a couple.

Qualifying Events include:

  • Voluntary or involuntary termination of the covered employee's employment for reasons other than gross misconduct.
  • Reduced hours of work for the covered employee.
  • Divorce or legal separation of a covered employee.
  • Death of a covered employee
  • Loss of status as a depenedent child under plan rules.

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How and when can I enroll for these programs?

COBRA continuation coverage is available upon the occurrence of a qualifying event that would cause an individual to lose his or her health care coverage.

The District notifies our Third Party Administrator, AmeriHealth Administrators, of a qualifying event within 30 days.  You must notify the Benefits department of a qualifying event within 60 days after divorce or legal separation or a child's ceasing to be covered as a dependent under plan rules.

AmeriHealth Administraotrs will mail you an election notice not later than 14 days after we notify them that a qualifying event has occurred. Once received, the individual then has up to 60 days to decide whether to elect COBRA continuation coverage. The qualified beneficiary has 45 days after electing coverage to pay the initial premium.  Coverage is not accessible until enrollment and Payment have been made to AmeriHealth Adminsitrators:  PO Box 990, Horsham, PA 19044-0990. You are responsible for ensuring delivery and confirming receipt.

The notice will list the last date your Health Benefits Continuation Plan Enrollment Form can be received by AmeriHealth Administrators.  The Premium Computation Form indicates the amount due and the date it must be received by AmeriHealth Administrators.  If do not send payment with the Enrollment Form, coverage will not be active until payment is received.  YOU WILL NOT BE BILLED.

See this Sample COBRA Election for guidance.

Once you have completed the enrollment application and payment, you will receive a printed sheet of coupons with your account number and mailing address.  Coupons will run through the end of the following JUNE or the end of your eligibility, whichever is earlier.  Payments are due on the first day of each month and must be postmarked no later than the last day of the month for which they are due. Failure to pay premiums by the due date will result in the cancellation of your participation in the Health Benefits Continuation Plan. There are no exceptions for COBRA subscribers.

Contact information for AmeriHealth Administrors is:

AmeriHealth Administrators

Attn: COBRA Department

1900 Market Street

Suite 500

Philadelphia, PA 19103

Toll free: (888) 547-5090

Email: BenefitsOutsourcing@ahatpa.com

Fax: (215) 761-0905

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When and how can I make changes or cancel participation?

The School District of Philadelphia permits COBRA subscribers to add eligible dependents to their coverage during our annual open enrollment in May, effective July, or within 30 days of a qualifying event.  Open Enrollment notices are mailed to subscribers in late April.  This is your opportunity to add or remove an eligible dependent or switch between HMO and PPO plans without a qualifying event.  Completed forms and documentation must be submitted to AmeriHealth Administrators as directed in the notice.

Please click here for information on Open Enrollment for Continuants, COBRA and Retirees.  

You may drop COBRA coverage at the end of any month. You may also drop part of your coverage (i.e., dental, prescription and Vision) or remove dependents at the end of any month. Contact AmeriHealth Administrators in writing of any change requests.  Be sure to notify AmeriHealth Administrators of changes so coverage is not terminated for non payment.

Note, you may not add coverage or dependents except at Open Enrollment or in case of a family status change.

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My dependent child is no longer eligible for insurance through the District. Can he or she enroll in COBRA?

 

A dependent that loses benefits may elect to continue group health coverage on a self-pay basis for up to 36 months. They must enroll with AmeriHealth to continue COBRA.  The coverage start date MUST be the same as the date coverage was lost. No break in coverage is permitted.

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What does it cost and how do I make payments?

 

When you were an eligible employee, the District paid a large part of your group health premiums. Under COBRA, as a qualified beneficiary, you will pay the entire premium amount plus a 2% administrative fee.

While COBRA rates may seem high, you will be paying group premium rates, which are usually lower than individual rates.

Since it is likely that there will be a lapse of a month or more between the date of separation and the time you make your COBRA election decision, you may have to pay health premiums retroactively-from the time of separation. The first premium, for instance, will cover the entire time since your last day of coverage.

You should also be aware that it is your responsibility to pay for COBRA coverage even if you do not receive a monthly statement.  Checks returned for insufficient funds or checks that otherwise cannot be cashed do not constitute payment. Once coverage is lost, it cannot be reinstated.

Premiums adjust annual effective July 1.  The chart below details the current premium structure for July 1, 2016 through June 30, 2017.

Click here for a printer friendly copy

School District of Philadelphia

Continuation Rates effective July 1, 2016.


Plan Election/ Coverage Level

Single

Parent Child

Parent Children

Subscriber Spouse

Family

KEYSTONE-HMO 15

 $587.42

 $822.39

 $1,057.34

 $1,174.83

 $1,762.26

HMO 15 w/dental

$625.00

 $890.02

 $1,142.55

 $1,242.46

 $1,847.47

HMO 15 w/prescription & vision

$735.96 $1,208.60

 $1,443.55

 $1,561.04

 $2,148.47

HMO 15 w/prescription & vision & dental

 $773.54

 $1,276.23

 $1,528.76

 $1,628.67

 $2,233.68

PERSONAL CHOICE  20/30/70(PPO)

 $693.52

 $970.93

 $1,248.34

 $1,387.05

 $2,080.57

PPO 20/30/70 w/dental

 $731.10

 $1,038.56

 $1,333.55

 $1,454.68

 $2,165.78

PPO 20/30/70 w/prescription & vision

 $842.06

 $1,357.14

 $1,634.55

 $1,773.26

 $2,466.78

PPO 20/30/70 w/prescription & vision & dental

 $879.64

 $1,424.77

 $1,719.76

 $1,840.89

 $2,551.99

PERSONAL CHOICE Mod 320(PPO)

 $585.18

 $819.26

 $1,053.33

$1,170.37

 

                         $1,755.54

PPO 320 w/dental

$622.76

$886.89

$1,138.54

$1,238.00

$1,840.75

PPO 320 w/prescription & vision

$733.72

$1,205.47

$1,439.54

$1,556.58

$2,141.75

PPO 320 w/ prescription & vision & dental

$771.30

$1,273.10

$1,524.75

$1,624.21

$2,226.96

 

 

 

 

 

Dental

$37.58

$67.63

$85.21

$67.63

$85.21

Prescription and Vision

$148.54

$386.21

$386.21

$386.21

$386.21

                         

 

 

 

 

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How do I use this benefit?

Your COBRA coverage is exactly the same coverage you had as an active employee. Usually you can use the same card, submit claims in the same way, and call the same Customer Service Number you used previously.

NOTE:  It is your responsibility to notify the School District Benefits office and Independence Blue Cross of alternate coverage so that Coordination of Coverage information can be updated.  By law, Medicare or coverage based on a spouse’s employment, is primary to COBRA coverage, meaning you must show your provider that insurance first and use those plan benefits before you can access the COBRA benefit. 

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Frequently Asked Questions

Who is AmeriHealth Administrators?  AmeriHealth Administrators is a company contracted by the School District to handle the distribution of COBRA enrollment materials, process your enrollment and handle payment processing and monitor your eligibility.  You will be enrolled in the same Keystone or Personal Choice coverage you had through Independence Blue Cross while you were an eligible employee.

How do I know when my coverage ends?  Your initial enrollment materials will list the number of months coverage for which you are eligible.   Each year you will receive coupons through the following June or the end of your eligibility, whichever is sooner.  AmeriHealth Administrators will mail you a notice several months before your coverage ends.  You should plan in advance (see Alternatives to COBRA) so you are able to enroll in coverage with no break. 

Who do I contact with a question?  Contact AmeriHealth Administrators at 888-547-5090 regarding your enrollment, premium payment, changes to your enrolled dependents, or information on how long your coverage extends.  Continue to call the number on the back of your membership ID card (1-800-ASK-Blue) for information about participating providers, precertification, specific benefits, and claims issues.

When are my payments due?  Payments are due on the first day of each month and must be postmarked no later than the last day of the month for which they are due.   Keep in mind that your first payment may be for a period of more than one month.  It will cover the entire time since your last day of coverage.  Enclosed in your enrollment materials is a Premium Computation Form that lists the amount due based on the date your initial enrollment is received by AmeriHealth Adminsitrators.  It is your responsibility to pay for coverage even if you do not receive a monthly statement. 

What is considered a late payment?  Payments are due on the first day of each month.  Payment received after that time are late.  If you do not send the full amount listed on the Premium Computation Form with your initial enrollment, your subsequent payments will all be late. 

How can I get benefits and services during the interim between the end of my active coverage and the reinstatement of my COBRA coverage?  If you need services, like a Doctor's visit, you may have to pay for the visit and then submit it for reimbursement. The doctor's office may be willing to hold or resubmit the bill when your coverage is reactivated.

If I elect COBRA, am I obligated to pay for the full COBRA period?  No. You may drop COBRA coverage at the end of any month. You may also drop part of your coverage (i.e., dental, prescription and Vision) or dependents at any time. However, you may not add coverage or dependents except at Open Enrollment or in case of a family status change.

If I waive COBRA coverage during the election period, can I still get coverage at a later date?   You may only elect COBRA coverage within the 60 day election period. If you or a qualified beneficiary waives COBRA coverage during the initial 60 day election period, he or she may revoke the waiver of coverage before the end of the election period. A beneficiary may then elect COBRA coverage.  If you are a qualified retiree, refer to our PA Acts 110/43 section.

What is a Qualifying Event?  Qualifying events are certain events that would cause an individual to lose health coverage. The type of qualifying event will determine who the qualified beneficiaries are and the amount of time that a plan must offer the health coverage to them under COBRA.

Qualifying Events for Employees:

  • Voluntary or involuntary termination of employment for reasons other than gross misconduct
  • Reduction in the number of hours of employment

Qualifying Events for Spouses:

  • Voluntary or involuntary termination of the covered employee's employment for any reason other than gross misconduct
  • Reduction in the hours worked by the covered employee
  • Covered employee's becoming entitled to Medicare
  • Divorce or legal separation of the covered employee
  • Death of the covered employee

Qualifying Events for Dependent Children:

  • Loss of dependent child status under the plan rules
  • Voluntary or involuntary termination of the covered employee's employment for any reason other than gross misconduct
  • Reduction in the hours worked by the covered employee
  • Covered employee's becoming entitled to Medicare
  • Divorce or legal separation of the covered employee
  • Death of the covered employee

I am 10-month teacher and not planning to return for the new school year. When does my medical coverage end?  You must submit your notice of resignation or retirement by April 15 that you are not returning for the new school year. If you submit your notice to retire or resign during July or August, your medical coverage will terminate as of July 1.  Please review here for details on coverage for July and August. 

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