SSMC Employee Health Benefit Plan
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7. COBRA Coverage and Pre-existing Conditions. The Health Insurance Portabilit y and Accountability
Act of 1996 (HIPAA), a federal law, makes it easier for an employee to change jobs and become covered
by a new employer's plan even if the employee or his or her dependents have a pre-existing medical
condition. COBRA beneficiaries must notify the SSMC Human Resources Department when they become
covered under another employer or other Group plan.
HIPAA requires that the time, in which you and your Dependents had continuous health coverage
(including COBRA) before changing jobs, will reduce, day by day, the new plan's preexisting condition
exclusions. In this situation, COBRA coverage ends for a beneficiary when that beneficiary becomes
covered under the new employer's group health plan and pre-existing limitations do not apply to that
beneficiary. In general, if a beneficiary or participant had health coverage for the previous 12 months, he
or she will be covered by a new employer's plan without regard to any pre-existing conditions. Contact
your new employer to verify your coverage and any applicable pre-existing exclusion. If you or your
Dependents become eligible under a new plan, you should contact the SSMC Human Resources
Department to send you a coverage certification under this Plan. When your COBRA coverage ends, you
will be provided with a coverage certification that will describe the duration of your coverage under
COBRA. Your new employer may request coverage certifications.
Please Note
Any individual who elects to continue coverage under COBRA will be eligible for the same coverage in effect at the
time that person first lost Plan eligibility status. Subsequent Plan Amendments apply to COBRA continuation in the
same manner as for individuals who maintained Plan coverage eligibility requirements. Benefits will not be payable
for Covered Expenses Incurred during a period of COBRA continuation until the applicable COBRA Participation
Payment has been made for that period of continuation.
This continuation coverage could be secondary payer after other group plans or Medicare. See Section VII -
Coordination of Benefits. If a COBRA participant is already eligible for Medicare when COBRA continuation takes
effect, the Medicare Secondary Payer Rules for persons without employment status may apply. If not already enrolled
in Medicare, persons without employment status should do so immediately. Refer to Section VI - Medicare
Integration with Plan Benefits. If a person becomes eligible for Medicare or another health plan after COBRA
continuation takes effect, continuation coverage under this Plan will end on the effective date of Medicare or another
plan coverage.
H. Plan Cancellation
It is the intent of SSMC to continue the Plan for an indefinite period. However, SSMC reserves the right to
cancel the Plan or make changes in the Plan at any time with respect to Plan provisions and claims
administration and Participation Payment rates. Some possible reasons why this Plan could end would be
installation of a revised successor plan; merger, transfer, or consolidation with another health plan; or changes
in economic conditions, laws, or corporate structure that would make the Plan unfeasible as it currently exists.
If Plan ends or coverage changes, Covered Expenses Incurred while Plan coverage was in effect will continue
to be processed according to the Plan rules in effect at the time the expenses were Incurred. If this Plan cancels
or terminates, Plan payment for expenses Incurred on or after the date of cancellation or termination will not be
provided for any Plan Participant. If the Plan cancels, coverage will end for all persons enrolled in the Plan.
I. Certificates of Creditable Coverage
The Health Insurance Portability and Ac countability Act of 1996 (HIPAA), a federal law, makes it easier for an
employee to change jobs and become covered by a new employer's plan even if the employee or his or her
Dependents have a preexisting medical condition. Effective 7/1/97, HIPAA requires that time, during which
you and your Dependents had continuous health coverage (including COBRA) before changing jobs, will
reduce, day by day, the new plan's preexisting conditions exclusions. Generally, this law applies to each plan
based on the begin ning of its plan year. In general, if a beneficiary had health coverage for the previous 12
months, he or she will be covered by a new employer's plan without regard to any pre-existing conditions. To
comply with the HIPAA provisions, this Plan will send you a certificate of creditable coverage that will show
