Who is entitled to benefits?

 

There are three elements to qualifying for COBRA benefits. COBRA establishes specific criteria for plans, qualified beneficiaries, and qualifying events. These elements will determine the Period of Coverage.

 

Period of Coverage

 

Qualifying Events Beneficiary Coverage
Employment termination or reduced hours Employee, spouse, dependent child 18 months*
Employee enrolled in Medicare Spouse/Dependent child 36 months
Divorce or legal separation Spouse/Dependent child 36 months
Death of covered employee Spouse/Dependent child 36 months
Loss of "dependent child" status Dependent child 36 months

 

*In the case of certain individuals who are disabled within the meaning of the Social Security Act, special rules may apply to extend coverage an additional 11 months (from 18 to 29 months) to that individual and other individuals who are qualified beneficiaries with respect to the same qualifying event. See Notice Procedures, Duration of Coverage and Paying for COBRA Coverage for more information regarding the disability-based 11-month extension. Also, the 18-month (or 29-month) period of coverage may be extended to 36 months for a spouse or dependent child who is a qualified beneficiary and experiences a second qualifying event during the initial 18-month (or 29-month) period of continuation coverage. See Duration of Coverage for more information about second qualifying events.

Plan Coverage

 

Group health plans for employers with 20 or more employees on more than 50 percent of their typical business days in the previous calendar year are subject to COBRA. Both full- and part-time employees are counted to determine whether a plan is subject to COBRA. Each part-time employee counts as a fraction of an employee, with the fraction equal to the number of hours that the part-time employee worked divided by the hours an employee must work to be considered full-time.

 

Qualified Beneficiaries

 

A qualified beneficiary generally is an individual covered by a group health plan on the day before a qualifying event and is an employee, the employee's spouse, or an employee's dependent child. In certain cases, a retired employee, the retired employee's spouse, and the retired employee's dependent children may be qualified beneficiaries. In addition, any child born to or placed for adoption with a covered employee during the period of COBRA coverage is considered a qualified beneficiary. Also, agents, self-employed individuals, independent contractors and their employees, directors, political appointees and elected officials who participate in the group health plan may be qualified beneficiaries.

 

Qualifying Events

 

"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. A plan, at its discretion, may provide longer periods of continuation coverage.

 

The qualifying events for employees are:

 

  • Voluntary or involuntary termination of employment for reasons other than "gross misconduct"
  • Reduction in the number of hours of employment
  • The qualifying events for spouses are:
  • 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
  • The qualifying events for dependent children are the same as for the spouse with one addition:
  • Loss of "dependent child" status under the plan's rules