COBRA

Under a Federal law called the "Consolidated Omnibus Budget Reconciliation Act" (COBRA), you and your eligible covered dependents may continue your group health benefits under the Plan when your coverage is lost due to a "Qualifying Event." You and your spouse and/or dependent children must apply for coverage under COBRA following the Qualifying Event. Then, you must make monthly payments in order to keep your coverage.

Qualifying Event	Who May Purchase Continuation Coverage	Duration of Continuation Coverage
Your employment terminates	You, your spouse and your dependent children who were covered under the Plan when coverage was lost	18 months
Your working hours are reduced, i.e., you become a part-time Employee	You, your spouse and your dependent children who were covered under the Plan when your status changed	18 months
You experience a termination or reduction in hours while you are disabled (as determined by the Social Security Administration)	You, your spouse and your dependent children	29 months (18 months plus an additional 11 months)
You divorce, or your marriage is annulled	Your spouse and your dependent children who were covered under the Plan at the time of divorce, marriage or annulment	36 months
Your dependent child no longer qualifies as a dependent	Your dependent child	36 months
You die	Your spouse and your dependent children who were covered under the Plan at the time of your death	36 months

UVA Health Plan COBRA Information

What You Need to Do UVA Health Plan members must make a written request to continue benefits under COBRA. A written request must be received within 60 days of the date of the letter of Notification or the date of the Qualifying Event, if later. You should review the letter of Notification you receive (if any) from the COBRA Administrator regarding the amount of self-payment to be paid and when the first and subsequent self-payments will be due. No additional notices will be sent. Review the COBRA eligibility and payment information and complete the enrollment form.

Coverage Period UVA Health Plan members may continue your coverage and/or the coverage for your dependents for a maximum of 18 months (except as noted in the above chart under "duration of continuation coverage"). If a dependent has a second qualifying event while continuing his coverage as a result of your termination or change in employment, then the maximum period is measured from the first qualifying event that applied to the dependent.

Cost of Coverage The amount of self-payment to be paid by the covered UVA Health Plan person shall be 102% of the applicable premium (total cost of Plan coverage for a Participant), in accordance with procedures permitted by applicable law. Coverage will not be provided if self-payments are not made, in full, when due. No claims will be paid for any medical expenses incurred by a person during any period for which self-payments have not been made. Reimbursements for covered expenses incurred will only be made when all required self-payments have been made.

COBRA - High Premium
	Rate	Military LWOP Active Duty Employee Rate	Military LWOP Active Duty Employer Rate
Single	$453.90	$49	$396
Employee and Child	$898.62	$171	$710
Employee and Spouse	$929.22	$199	$712
Family	$1,453.50	$382	$1,043

COBRA - Low Premium
	Rate	Military LWOP Active Duty Employee Rate	Military LWOP Active Duty Employer Rate
Single	$416.16	$12	$396
Employee and Child	$772.14	$47	$710
Employee and Spouse	$781.32	$54	$712
Family	$1,182.18	$116	$1,043

Address Changes after Enrolling in COBRA

In order to protect your family's rights, you should keep the COBRA Administrator, Chard Snyder, at 1.800.982.7715, informed of any changes in addresses of family members.

Be sure to contact UVA Human Resources Benefits Divisionif you are moving away from the Southern Health network area as you may need to enroll in the National Network.

For information on COBRA rates and enrollment and to enroll in the National Network, you may contact the UVA Human Resources Benefits Division at 434.982.0123.

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COBRA Summary Information

Chard Snyder COBRA Customer Service - 1.888.878.6175

Links and Forms

• COBRA Enrollment Form