The terms of the insurance contract(s) shall determine coverage eligibility and payment of all benefits; employees should not rely solely on verbal statements or summaries for interpretation of these documents.
In the event the City reasonably suspects abuse of any health benefits provided herein, it may request from any insurance company or service provider the utilization information of individual Layton employees and/or dependents relative to the suspected abuse. Access to such information by any other party shall be limited by the City as required by State Law.
Medical and Dental Insurance
Provision and administration of medical and dental insurance are governed in accordance with current plan documents and applicable federal and state laws.
Regular full-time City employees working more than 35 hours per week on an annual basis are eligible for medical and dental insurance coverage offered by the City. The City may provide a proportionately reduced contribution for those employees working less than 40 hours per week unless otherwise required by law.
Beginning July 1, 1997, new hires wishing to reduce the length of the pre-existing condition limitation according to HIPAA legislation must provide proof of creditable coverage from their previous employer. The period of a new employee’s pre-existing condition limitation under the City’s medical insurance plan will be reduced by the period(s) the person had coverage under a creditable plan, provided there was no break in coverage of 63 or more days between coverage.
Plans Made Available to Eligible Employees
At the present time, the medical and dental plan offered to employees is the City's partially self-funded plan administered through Select Health. The plan administrator shall be the City Manager or his/her designee.
The employee must submit a completed enrollment form to the Human Resources Officer within thirty-one (31) days of hire to be eligible for benefit coverage.
Special Enrollment Periods
- An eligible person who has declined to enroll when first eligible because of other coverage in effect at that time may enroll within 31 days of (1) exhausting COBRA continuation coverage, if that other coverage was COBRA continuation coverage; or (2) losing that other coverage due to loss of eligibility (e.g. divorce, death, termination of employment), if it was not COBRA continuation coverage; or (3) cessation of employer contributions to that other coverage, if it was not COBRA continuation coverage.
- A dependent acquired through marriage, birth, adoption, or placement for adoption and other eligible persons who had previously declined to enroll when first eligible may enroll within 31 days of the date the dependent is acquired.
- Persons not enrolling when first eligible or during a Special Enrollment Period are late enrollees.
- Late enrollees will be allowed to enroll only at the next annual open enrollment period which is each June, with coverage effective the following July 1st.
- An 12-month pre-existing condition limitation (less any creditable coverage) will apply to late enrollees who are over the age of 19.
Insurance booklets should be provided to new employees and additional copies can be obtained from the Human Resources Officer upon request.
Effective January 1, 2006, the employee shall contribute $ 68.25 per pay period ($147.88 per month). Contribution rates may change without notice. The City contributes the remaining cost of the group medical and dental premium, for the employee and the employee's dependents. All fund balances in this plan belong to the City.
Regular full-time employees are covered by life insurance, paid by the City that is in effect during employment with the City. The present policy provides $30,000 of coverage for general employees, $100,000 of coverage for department directors, and $2,000 for each dependent.
Employee Assistance Program
Regular full-time employees and their immediate family members are covered by an Employee Assistance Program as of July 1, 1995. The EAP provides limited confidential counseling services by trained counselors at no cost to the employee. These services are available twenty-four (24) hours a day, seven (7) days a week. An employee or their dependent can request assistance from the EAP by calling the Ogden office at (801) 392-6833 or 1-800-395-7850 anywhere within Utah. The EAP premium is fully paid by the city.
Employees covered under the City's partially self-funded medical and dental plan are automatically covered on the Vision Service Plan. Coverage under the vision plan shall be for the same number of dependents currently covered by the medical insurance.
During FY 2005-2006, the City and employees are required to contribute according to the following schedule:
VISION INSURANCE PREMIUMS (FY2005-2006)
Per Pay Day
Per Pay Day
Employee plus 1 dependent
Employee plus 2 or more dependents
COBRA (Continuation of Coverage)
COBRA is an acronym for the Consolidated Omnibus Budget Reconciliation Act of 1985, which may provide the opportunity for limited continuation of group health plan (the Plan) coverage for city employees and their dependents when they would otherwise lose such coverage due to certain events known as “qualifying events”. Specific qualifying events are listed in this policy. After a qualifying event, COBRA continuation coverage is to be offered to each person who is a “qualified beneficiary”. The employee, the employee’s spouse and children may become qualified beneficiaries if coverage under the Plan is lost due to the qualifying event.
Plan coverage consists of city offered health, dental and vision insurance, and the employee assistance program (EAP). In addition, employees participating in the medical reimbursement portion of the flexible spending plan may elect to continue participation in that plan until the following June 30th.
Under COBRA, qualified beneficiaries who elect this coverage will be required to pay 100% of the insurance premiums (both the employer’s and employee’s portions) plus a 2% administration fee. Monthly premium payments are due on the 1st of each month. If the COBRA premium payment is not received within 30 days of the due date, COBRA coverage may be cancelled and any remaining months of continuation eligibility will be forfeited.
If an employee's termination of employment is for gross misconduct, the employee and any dependents will not qualify for the COBRA premium reduction.
Each full-time employee is a qualified beneficiary entitled to elect COBRA continuation coverage if the employee’s coverage under the Plan is lost because either one of the following qualifying events happens:
- The employee’s hours of employment are reduced, or
- Employment ends for any reason other than the employee’s gross misconduct.
The spouse of a full-time employee is a qualified beneficiary entitled to elect COBRA continuation coverage if coverage under the Plan is lost because any of the following qualifying events happens:
- The employee’s spouse dies;
- The employee’s hours of employment are reduced;
- The employee’s employment ends for any reason other than gross misconduct;
- The employee becomes eligible for Medicare benefits (under Part A, Part B, or both); or becomes divorced or legally separated from the employee’s spouse. In the event the employee reduces or terminates coverage under the Plan for the employee’s spouse in anticipation of a divorce or legal separation which later occurs, the divorce or legal separation may be considered a qualifying event even though the coverage was reduced or terminated before the divorce or separation.
Dependent Children Eligibility
Dependent children of a full-time employee, including any child born to or placed for adoption with a covered employee during the period of COBRA coverage who is thereafter properly enrolled in the Plan, or a child of the covered employee who is receiving benefits under the Plan pursuant to a qualified medical child support order are qualified beneficiaries entitled to elect COBRA continuation coverage if coverage under the Plan is lost because any of the following qualifying events happen:
- The parent-employee dies;
- The parent-employee’s hours of employment are reduced;
- The parent-employee’s employment ends for any reason other than the employee’s gross misconduct;
- The parent-employee becomes eligible for Medicare benefits (Part A, Part B, or both);
- The parents become divorced or legally separated; or
- The child stops being eligible for coverage under the plan as a “dependent child.”
Written Notification of Qualifying Event is Required
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Human Resources Officer (Plan Administrator) has been properly notified in writing that a qualifying event has occurred. If procedures outlined below are not followed, the Plan is not obligated to provide COBRA rights.
Responsibility of Employees to Provide Written Notification
Employees, or other qualified beneficiaries, must provide written notice of the occurrence of the following qualifying events to the Human Resources Officer (Plan Administrator):
- A spouse covered under the Plan becomes divorced or legally separated from the covered employee;
- A spouse becomes eligible for Medicare benefits (under Part A, Part B, or both);
- A child covered under the Plan ceases to be eligible for coverage under the Plan as a “dependent child.”
- The occurrence of a second qualifying event (i.e. spouse becomes divorced or legally separated, or child ceases to be a dependent, or employee dies, or a covered employee becomes entitled to Medicare) after the qualified beneficiary has become entitled to COBRA with a maximum duration of 18 or 29 months;
- A qualified beneficiary, determined by the Social Security Administration (SSA) to be disabled during the first 60 days of COBRA coverage, must notify the Human Resources Officer (Plan Administrator) in writing of the disability determination within 60 days after the date of determination and before the end of the first 18 months of COBRA.
- A qualified beneficiary, with respect to whom a notice of disability determination has been provided, must notify the HR Officer (Plan Administrator) of a subsequent determination by the SSA that he or she is no longer disabled within 30 days of the final determination.
Procedure to Notify Plan Administrator
The required written notice for each of the events listed above may be made as follows:
- Obtain a blank Notice of COBRA Event Form from the Human Resources Division of the Management Services Department;
- Submit a completed and signed Notice of COBRA Qualifying Event Form to the Human Resources Officer (Plan Administrator) within 60 days after the later of (1) the date the qualifying event occurs, (2) the date on which the qualified beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the qualifying event. Note that the disability determination events (5 and 6 above) have additional reporting deadlines.
- Mail or hand deliver this notice to:
Human Resources Officer
Layton City Corp.
437 N. Wasatch Dr.
Layton, UT 84040
- Oral notice, including notice by telephone, is not acceptable. Electronic (including e-mailed or faxed) notices are not acceptable. If mailed, your notice must be postmarked no later than the deadline described above. If hand-delivered, your notice must be received by the individual at the address specified above no later than the deadline described above.
Responsibility of Employer to Provide Notification
When the qualifying event is the end of employment (other than for gross misconduct) or reduction in hours of employment, death of the employee, covered employee’s becoming eligible for Medicare or employer bankruptcy, the employer is responsible to notify the Plan Administrator (HR Officer) of the qualifying event.
Rights to Elect COBRA
Once the Plan Administrator receives proper notice that a qualifying event has occurred, COBRA continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage on behalf of their spouses, and parents may elect COBRA continuation coverage on behalf of their children. If COBRA continuation coverage is not elected within the 60-day election period, a qualified beneficiary will lose the right to elect COBRA continuation coverage.
Duration of COBRA Coverage
COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the employee, the employee’s becoming eligible for Medicare benefits (under Part A, Part B, or both), the employee’s divorce or legal separation, or a dependent child’s losing eligibility as a dependent child, COBRA continuation coverage may last for up to a total of 36 months.
When the qualifying event is the end of employment or reduction of the employee’s hours of employment, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the employee lasts until 36 months after the date of Medicare entitlement.
For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse and children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus 8 months).
Otherwise, when the qualifying event is the end of employment or reduction of the employee’s hours of employment, COBRA continuation coverage generally lasts for up to a total of 18 months.
Extension of the 18-Month Period of Continuation Coverage
There are two ways in which this 18-month period of COBRA continuation coverage can be extended:
- If the employee or any dependent of the employee covered under the Plan is determined by the Social Security Administration to be disabled and the Plan Administrator is notified in a timely manner, the employee and the employee’s dependents may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. The disability would have had to be determined by the SSA to have started at some time before the 60th day of COBRA continuation coverage and must continue at least until the end of the 18-month period of continuation coverage. The Plan’s procedures for providing this notice are included above in the “Procedure to Notify Plan Administrator” section of this policy. If these procedures are not followed or if the notice is not provided in writing to the Plan Administrator during the 60-day notice period and within 18 months after the covered employee’s termination of employment or reduction of hours, there will be no disability extension of COBRA continuation coverage. The affected individual must also notify the Plan Administrator within 30 days of any final determination that the individual is no longer disabled.
- If the employee or any dependents of the employee experiences another qualifying event while receiving 18 months of COBRA continuation coverage, each can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly made to the Plan. This extension may be available to the spouse and any dependent children receiving COBRA continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event not occurred. The Plan’s procedures for this notice, including a description of any required information or documentation, the name of the appropriate party to whom notice must be sent, and the time period for giving notice, can be found in the most recent Summary Plan Description or by contacting the Plan Administrator. If these procedures are not followed or if the notice is not provided in writing to the Plan Administrator during the 60-day notice period, there will be no extension of COBRA continuation coverage due to a second qualifying event.
When COBRA Coverage Ceases
Continuation coverage will be terminated before the end of the maximum period if:
- Any required premium is not paid in full on time;
- A qualified beneficiary becomes covered, after electing continuation coverage, under another group health plan that does not impose any pre-existing condition exclusion for a pre-existing condition of the qualified beneficiary;
- A qualified beneficiary becomes entitled to Medicare benefits (under Part A, Part B, or both) after electing continuation coverage;
- The employer ceases to provide any group health plan for its employees;
- A qualified beneficiary engages in conduct that would justify the plan in terminating coverage of a similarly situated participant or beneficiary not receiving continuation coverage (such as fraud).
If You Have Questions
Questions concerning the applicable Plan or COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about employee and their dependent’s rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.)
Statement Regarding More Complete Information
This policy generally explains COBRA continuation coverage, when it may become available and what needs to be done to protect the right to receive it. For additional information about the employee’s and their dependent’s rights and obligations under the Plan and under federal law, you should review Layton City’s Summary Plan Description and contact the Human Resources Officer (Plan Administrator).
Keep Your Plan Informed of Address Changes
In order for employees and their dependents to be protected hereunder, employees and beneficiaries should keep the Plan Administrator informed of the current addresses and of any changes in the addresses of family members. Employees and their dependents should also keep a copy, for their own records, of any notices you send to the Plan Administrator.
Plan Contact Information
The name of the group health plan and name, address and telephone number of the party or parties from whom additional information about the plan and COBRA continuation coverage can be obtained on request are as follows:
Plan Administrator: Kiley Day
Layton City Human Resources Officer
437 North Wasatch Drive
Layton, UT 84041
Third Party Administrator: Denise Oyler
4646 West Lake Park Boulevard
Salt Lake City, UT 84120