2023/11/29 Council Agenda Packet

© Peak One Administration 2016 26 FEDERAL COBRA SERVICES Appendix The Client has independently concluded that one or more of its Benefit Plans for which PSP has provided the sample plan documentation or, if PSP’s sample plan documentation is not utilized, then only such plans identified by Client and agreed to by PSP pursuant to separate written notice, provide medical care and are subject to the provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (“COBRA”), as subsequently amended. Consequently, Client is required to perform certain acts in order to comply with COBRA. Client has engaged PSP to provide services related to COBRA administration for the following Benefit Plans: [Delineate Names of Applicable Plan(s)] (“Health Plans”) The effective date of this Service Appendix is the effective date of the Agreement or if later, the date that both parties have signed this Service Appendix as set forth below. The responsibilities of the parties set forth in this Service Appendix are in addition to any responsibilities set forth in the Agreement. If there is a conflict between this Service Appendix and the Agreement, the Agreement controls. A. PSP Responsibilities The services PSP will perform pursuant to this Appendix for the Health Plans are limited to the following: 1. Initial COBRA Notice. PSP will distribute an Initial COBRA Notice by First Class Mail with Proof of Mailing to: the last known address, provided by Client, of each covered employee and, when required by applicable law, the covered spouse and/or dependents. After the effective date of this Agreement, PSP will send the Initial COBRA Notice to: (a) employees and, when required by applicable law, the covered spouse and/or dependents, who first become eligible under Health Plans after the effective date of this Agreement; or (b) all covered employees and, when required by applicable law, the covered spouse and/or dependents, under the Health Plans on the effective date of this Agreement. Such Initial Notice will be distributed to covered employees and/or covered spouses and/or dependents (if enrolling at a different date) as soon as reasonably possible but no later than fourteen (14) days after receiving the required information from the Client. 2. Election Notice. PSP will distribute a COBRA qualifying event notice and election form (collectively the “Election Form”) to the address provided by Client of each Qualified Beneficiary entitled to elect federal COBRA continuation coverage after the effective date of this Agreement, unless all Qualified Beneficiaries reside at the same address, in which case a single Election Form will be distributed in accordance with applicable law. Such notice will be distributed to Qualified Beneficiaries as soon as reasonably possible but no later than fourteen (14) days after receiving the required information from the Client. PSP will also notify Qualified Beneficiaries of their right to an extension of COBRA continuation coverage upon proper notification of a second qualifying or determination of disability event that occurs during the eighteen (18) or twenty-nine (29) month COBRA period (if applicable) provided that the Qualified Beneficiary has timely and properly notified PSP of a second qualifying event or disability determination. Such notice will be sent as soon as reasonably possible, but no later than, five (5) days after receipt of written notice of such event from the affected Qualified Beneficiary (or any other qualified beneficiary).