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HHRC-EOC 02.10.2017 11 Evidence of Coverage Subscriber’s death. Spouse ceases to be eligible due to divorce or legal separation. Loss of dependent status by a Dependent enrolled in the group benefit plan. With respect to a covered Dependent only, the Subscriber’s entitlement to Medicare. Group must notify Plan within thirty (30) days of a termination of employment or reduction in work hours, which would result in ending coverage under the Member’s group benefit plan. Failure to notify Plan within sixty (60) days of the occurrence of a Qualifying Event will disqualify the Member from receiving continuation coverage. Notifications of a Qualifying Event are generally made to Group, or Group’s COBRA administrator. 3) Cal-COBRA Enrollment and Premium Information Within fourteen (14) days of receiving notification of a Qualifying Event, Group, or Group’s COBRA administrator, will send enrollment and premium information, including a Cal-COBRA Election Form. You must return the completed Cal-COBRA Election Form within the required time period. The Cal-COBRA Election Form must be received within sixty (60) days of the latest of these occurrences: The date coverage under the plan was terminated or will terminate due to a Qualifying Event; or The date you were sent the Cal-COBRA enrollment and premium information. Your Cal-COBRA premium payment must be received within forty-five 45 days of the date that your Cal-COBRA Election Form was received. Failure to send the correct premium amount within forty-five (45) days will disqualify you from continuation coverage under Cal-COBRA. The first premium payment equals the amount of all premiums due from the first month following the Qualifying Event through the current month. After the initial payment, Cal-COBRA premiums are due on the first day of each month. The Cal-COBRA premium is generally 110% of the premium charged to Group for employees. Your enrollment in Cal-COBRA will not occur until both your Cal-COBRA Election Form and your first Cal COBRA premium payment have been received. 4) Termination of Cal-COBRA Continuation Coverage Usually, a Member’s Cal-COBRA continuation coverage will last up to thirty-six (36) months. The continuation coverage shall end automatically if the individual becomes eligible for Medicare or becomes covered under any group health plan not maintained by the employer or any other health plan, regardless of whether that coverage is less valuable. Member’s Cal-COBRA continuation coverage may terminate early if: Member moves out of Plan’s service area; Member does not pay the required premium REV: 03-10-23 MI ATTY/AGR.2023.039/Aetna (EAP Services Agreement) (Page 35 of 42)