UFCW LOCAL 1776 and PARTICIPATING EMPLOYERS                                   HEALTH and WELFARE FUND

Changes in Coverage Continuing Coverage Under COBRA Under COBRA, you have the right to continue your group health care coverage for a period of time even after you are no longer employed. Your spouse (and dependent children) may also continue coverage if they would lose coverage for one of the reasons listed. Each individual covered under the Plan (you, your spouse, and your dependents) has the right to make his or her own decision about COBRA continuation coverage. Both you and your spouse should read this section. Qualifying Events Your right to continue coverage applies if you lose coverage because of one of the following events: Events that apply to employees    Your employment is terminated for any reason except gross misconduct.    Your work hours are reduced. Events that apply to spouse    Your spouse’s employment is terminated, or your spouse’s work hours are reduced.    Your spouse dies.    Your spouse becomes covered by Medicare.    You and your spouse become divorced. Events that apply to dependents    Your parent’s employment is terminated, or your parent’s work hours are reduced.    Your parent dies.    Your parent becomes covered by Medicare.    You no longer qualify as a “dependent” under the terms of the Plan. (Please refer to the section titled “Who is Eligible.”) Type of coverage Generally, you can elect to receive the same type of group health care coverage you had immediately prior to the qualifying event. However, your benefits will change if the Fund’s benefit plans change. You may also elect a less expensive level of coverage at the time you make your initial COBRA election. Maximum coverage period You, your spouse and dependents may elect to continue coverage up to a maximum period as follows:    Up to 18 months from the date coverage is lost in the event of your termination of employment or reduction in your work hours, or    Up to 29 months if you, your spouse or your dependent is found by the Social Security Administration (SSA) to have been disabled at any time during the first 60 days of your continuation coverage, but only if the disabled person (or a member of his or her family) notifies the Fund Administrator of SSA’s determination within 60 days after he or she receives the notice of the determination and before the end of the 18-month coverage period, or up to 36 months in all other cases.    If your spouse or your dependent has elected continuation coverage following your termination of employment or reduction in hours and a second qualifying event occurs during the initial 18-month period of continuation coverage (or 29-month period, if applicable), the total period of continuation coverage for your spouse and dependents may last up to 36 months from the date coverage was lost on account of your termination of employment or reduction in hours. Note: If you are found by the SSA to have been disabled as provided above, but you are not yet eligible for Medicare at the end of the 29-month period, you may continue your coverage until you become eligible for Medicare. Also, the disabled person (or a family member) must notify the Fund Administrator of a final determination by SSA that he or she is no longer disabled. Note: Continuation coverage begins on the date you would otherwise lose your group health care coverage. Newborn and Adopted Children If, while you are receiving continuation coverage, you have a child born or placed with you for adoption, you may immediately enroll the child. Note that the cost of providing COBRA continuation coverage to the child may increase the cost of the COBRA premium. In order to cover the child, you must notify the Fund office within thirty (30) days of the birth or placement for adoption. Please note that the child will be treated as a “qualified beneficiary” with independent COBRA rights. Therefore, if another event occurs during the initial 18-month period of continuation coverage, the child will be able to elect to extend coverage for a period of up to 36 months from the date coverage was lost on account of the participant’s termination of employment or reduction in hours. For example, if the covered employee dies or becomes covered by Medicare, or if the dependent ceases to meet the Fund’s definition of “dependent,” the child will be able to elect additional coverage extending 36 months from the date that the covered employee first began COBRA continuation coverage. Spouses If, while you are receiving continuation coverage, you get married, your new spouse may be enrolled immediately. Your spouse, however, will not be treated as a “qualified beneficiary” with independent COBRA rights. Please contact the Fund office for details. Cost of continuation coverage The charge for the coverage is equal to the Fund’s cost of providing group coverage plus two percent. This two percent charge covers a portion of the administrative cost to provide you the coverage. If there is an increase or decrease in the Fund’s cost, your future premiums will be adjusted accordingly. Notification requirements You must notify us In the event you are divorced, you or your spouse becomes covered under Medicare, or one of your children no longer qualifies as a dependent under the Plan, you must notify the Fund Administrator no later than 60 days after the event. IMPORTANT: It is your responsibility to advise the Fund office in writing when one of your dependents or your spouse is no longer eligible for coverage. If the Plan pays benefits to your former spouse or former dependent because you failed to properly notify the Plan, you will be responsible for all amounts paid by the Fund on his or her behalf after the date he or she is no longer eligible for coverage. The Fund may also attempt to collect any overpayment from your dependent or may deny you future benefits until the overpayment is recouped. We will notify you The Fund Administrator will notify you and your spouse of continuation coverage options within 14 days of the date you advise us of one of the above events or of the date your employer advises us of your termination of employment, reduction in hours or death. Election of continuation coverage You, your spouse and dependents will have at least 60 days to elect continuation coverage. This election period will end on the later of:    60 days from the date you would otherwise lose coverage, or    60 days from the date we mail the notice of continuation coverage to you and your spouse. Once you have made your election, you are required to pay the premium within 45 days of the date of the election. Note: If you incur covered expenses during the election period before you have made an election, your claims will not be processed until we receive your election forms. Termination of continuation coverage Your continuation coverage will end when one of the following occurs:    The last day of the 18, 29 or 36-month period as described above.    You fail to pay the premium for your continuation coverage when it is due. Your payment is due by the 1st day of the month for that month’s coverage. However, you have until the 10th day of the following month before we will actually cut-off coverage for failing to pay your premium.    The date you first become, after the election of continuation coverage, covered under another group health plan, unless the new plan contains a pre-existing condition exclusion or limitation which applies to you and applies to any pre-existing condition you may have.    The date you first become, after the election of continuation coverage, covered by Medicare.    Continuation coverage was extended for up to 29 months due to disability and SSA has made a final determination that the disabled person is no longer disabled.    The Fund ceases to provide any group health coverage to any employee. Coordination with subsidized coverage If there is a qualifying event, but your employer or the Fund provides coverage to you without charge on account of your disability, or on account of your taking a leave of absence pursuant to the Family and Medical Leave Act of 1993, then COBRA continuation coverage does not begin until the date you lose coverage because the subsidized coverage ceases. If you are still disabled at the end of the period of subsidized coverage, you may elect to receive self-pay coverage for a period of 12 months or elect continuation coverage under COBRA at that time. If you elect self-pay coverage, you will also be entitled to COBRA continuation coverage after your self-pay coverage ends, as described above in the section titled “If you become disabled.” Certificates of Creditable Coverage for Participants and Dependents (HIPAA) The Health Insurance Portability and Accountability Act (HIPAA) may be important to you if you (1) have a pre-existing condition, (2) cease coverage under the Fund, and (3) join a new group health plan which has a pre-existing condition exclusion. A pre-existing condition exclusion in an insurance plan means that your new insurer can refuse to pay for conditions for which you or your eligible dependents received medical advice, diagnosis, care or treatment within a certain number of months before you became covered under the new plan. HIPAA provides that if you obtain group health coverage under another plan within sixty-three (63) days of ceasing coverage under this Fund, the new group health plan may have to reduce the time during which it will not pay benefits for pre-existing conditions by the amount of time you had coverage under the Fund. You will have to present a “Certificate of Creditable Coverage” to your new health plan showing the amount of time you had coverage under the Fund. You will automatically receive a Certificate of Creditable Coverage after you cease coverage under the Fund. In addition, you have the right to request a certificate at any time within 24 months after you cease participation in the Plan.