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EFTA00296043

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CareWst 09 BlueCross BlueShield Cobra Selection Form For Continuation of Group Coverage With CareFirst BlueCross BlueShield or CareFirst BlueChoice, Inc. CareFirt'S, 0 V BlueChoice. The Consolidated Omnibus Budget Reconciliation Act of 1985, also known as "COBRA", requires that a group health plan sponsored by an employer who typically employs 20 or more employees offer employees and their families the opportunity for a temporary extension of health coverage (called "continuation coverage" or "COBRA coverage") at group rates, in certain instances where coverage under the plan would otherwise end ("qualifying events"). Certain employer-maintained group health plans are exempt from COBRA, including small-employer plans, church plans (or tax-exempt organizations controlled by or affiliated with a church), and government plans (the Public Health Service Act governs governmental plans and contains parallel provisions of the federal law). Generally, if a member qualifies for continued coverage, he or she must pay the full cost of the applicable coverage during this period, and any applicable administrative fee. If the qualifying member wishes to continue coverage beyond this period, he or she may apply directly to CareFirst BlueCross BlueShield or CareFirst BlueChoice, Inc. for direct pay non-group conversion coverage within 31 days after his or her continued group coverage ends. (Dental, drug and eye care programs are not available under the direct pay non-group conversion coverage.) In general, an employer must notify the health plan administrator within 30 days after an employee's "qualifying event" — death, job termination, reduced hours of employment, or eligibility for Medicare. In cases of divorce, legal marital separation, or a child's loss of dependent status, it is the employee or his or her family's responsibility to notify the health plan administrator within 60 days of the event. Once notified, the plan administrator then has 14 days

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