For Active Employees

Do I have to pay anything for benefits during a disability extension?

You do not have to pay anything toward the cost of coverage. You will, of course, have to pay any out-of-pocket expenses you incur if you use your health care benefits (deductibles, co-pays, etc.).
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Disability/Self-Pay Benefits/COBRA

Disability Extension of Benefits

Allows for the provision of benefits for you and your eligible dependents in the event you become disabled.

Eligibility

The extension of benefits is ONLY available if your Schedule of Benefits includes a disability extension of benefits.

Requirements

You are required to submit the following to the Administrative Office:

  • Proof that your disability started while you were working for a participating employer who contributes to this benefit;
  • Proof that you are entitled to benefits under Workers’ Compensation or State Disability; and
  • A doctor’s certification, in writing, that you are unable to perform your job as a result of an illness or injury.

Maximum Length of Extension

Coverage may extend for 12 or up to 18 months. Refer to your Summary Plan Description for complete details.

Coverage will continue until the earliest of:

  • The date the maximum period of disability ends;
  • The date you are no longer disabled; or
  • The date the doctor certifies, in writing, that you are no longer disabled.

Self-Pay Continuation of Benefits

Allows you to continue coverage for yourself and your eligible dependents in the event you lose eligibility as an active employee or disabled employee.

Benefits

If you lose eligibility as an active employee or disabled employee, you may continue coverage for yourself and your eligible dependents (excluding any disability extension or weekly disability benefits) by paying the cost of coverage yourself.

Maximum Self-Payments

Self-payments may be made for a maximum of 6 consecutive months. When you have exhausted the 6 months allowed for self-payment, you and your eligible dependents may continue the health care portion of your coverage under the provisions of COBRA. (Refer to information on COBRA below.)

Amount of Self-Payments

Each self-payment must be sufficient to cover the cost of the coverage provided, plus the cost of administration, for one month.

When Self-Payments Are Due

The first self-payment must be received by the Administrative Office before the first day of the month for which coverage is desired. Subsequent self-payments must be received in the Administrative Office prior to the first day of the month for which coverage is desired. Self-payments must remain continuous

COBRA Continuation Coverage

Provides the option to temporarily continue coverage if you or your qualified beneficiary lose eligibility.

Overview

  • Each family member may make a separate election.
  • If you elect the self-pay option (explained above), the number of months you receive benefits as a self-pay employee will count toward the months benefits are available under COBRA.
  • If you elect COBRA, you forfeit your rights to the self-pay option.
  • Any disability extension of benefits will apply toward your maximum period of COBRA continuation coverage.
  • Loss of coverage must be due to a “qualifying event” (see below for list of qualifying events).
  • You will be entitled to the same health care coverage under COBRA, including medical, prescription drug, mental health and substance abuse, dental, and vision. Coverage for life insurance, accidental death and dismemberment, disability benefit extensions, and weekly disability benefits is NOT provided under COBRA continuation coverage.

Qualified Beneficiaries

A qualified beneficiary is any individual (your spouse or dependent child) who was covered under the Plan on the day before you experienced a qualifying event. A child who becomes your dependent while you are covered under COBRA is also a qualified beneficiary.

Qualifying Events
 

Qualifying Event Who May Continue Coverage
  • Your voluntary resignation;
  • Termination of your employment for reasons other than gross misconduct; or
  • A reduction in your hours.

You, your spouse, and/or your dependent children covered under the Plan.

Your death.

Your spouse and/or your dependent children covered under the Plan.

Your divorce or legal separation from your spouse.

Your former spouse and/or your dependent children covered under the Plan.

Your child ceases to meet the Plan’s definition of an eligible dependent

The affected dependent child who was covered under the Plan.

Maximum Period of Continuation Coverage

The period of continuation coverage depends upon the qualifying event. Refer to page 15 of your Summary Plan Description for complete details.

Your Notification Responsibilities

You must notify the Administrative Office when:
 

Qualifying Event Notification Deadline

You become divorced or legally separated from your spouse.

No later than 60 days after the later of (1) the date of the qualifying event; (2) the date on which coverage would be lost under the Plan as a result of the qualifying event; or (3) the date you are informed of your responsibility to provide notice to the Administrative Office.

 

 

A child no longer qualifies as a “dependent child.”

A second qualifying event occurs while your dependents are in an 18-month COBRA continuation period.

You or your dependent is entitled to COBRA for a maximum of 18 months, and the either of you is determined to be disabled by the Social Security Administration.

No later than 60 days after the later of (1) the date of the disability determination by the Social Security Administration; (2) the date you are informed of your responsibility to notify the Administrative Office; or (3) the end of the first 18 months of COBRA continuation coverage.

The Social Security Administration determines that the person receiving COBRA Continuation Coverage is no longer disabled.

No later than 30 days after the later of (1) the date of the Social Security Administration determination that the qualified beneficiary is no longer disabled.; or (2) the date you are informed of your responsibility to notify the Administrative Office.

You should also notify the Administrative Office when you become eligible for Medicare.

 

Refer to your Summary Plan Description for complete details regarding COBRA continuation coverage and Medicare.

How to Provide Notice

You must complete and sign the Fund’s COBRA Event Notification Letter. If you have questions about how to fill out the form, contact the Administrative Office at 323-278-7030 or 800-499-8121. Make a copy of the notice for yourself before mailing it to the address below. You may also send a letter to the Fund identifying your name, the qualifying event that has taken place, the date of the event, and the date coverage would be lost because of the event.

Where to Send Your Notice

Address your notice to:

LOS ANGELES MACHINIST BENEFIT TRUST
PO Box 6149 Garden Grove, CA 92846

Deadline for Election

Once the Administrative Office is notified that you have experienced a qualifying event, it will send you and/or your dependents an election form and information regarding COBRA Continuation Coverage. You will have at least 60 days from the date your coverage terminates or, if later, 60 days from the date the Administrative Office sends you the notice to make a decision to elect COBRA Continuation Coverage.

Cost of Coverage

The premium rate will be included in the notice sent to you by the Administrative Office.

HMO Participants

If you are an HMO participant living in California, you can elect COBRA-like coverage. This coverage is not provided by the Los Angeles Machinist Benefit Trust. Call Member Services at your HMO for more information on your rights and how to elect coverage.