Leaving the Lumenos of Georgia Health Insurance Plan

You have certain rights as a Lumenos plan participant when you leave the Lumenos plan.

• When Coverage Ends
• Certificate of Coverage
• Coverage Under Special Circumstances
• Right to Purchase Continuing Coverage

When Coverage Ends

Benefit coverage for you under the Plan and the Lumenos plan option will end when the earliest of the following occurs:

• the State Health Benefit Plan discontinues the Plan
• the Plan is amended to exclude the specific group of employees of which you are a member
• you reach the individual maximum lifetime benefit under the Plan
• you fail to make required contributions for coverage
• you terminate employment with the company for any reason
• you cease to be an eligible employee

NOTE: If your participation in the Lumenos plan ends for any reason, any balance in your account will be forfeited back to the company.

Your dependents' coverage under the Plan will end when the earliest of the following occurs:

• the State Health Benefit Plan discontinues the Plan
• they no longer qualify as dependents under the Plan
• your coverage ends for any reason
• the Plan is amended to exclude the specific group of dependents to which they belong
• they reach the individual maximum lifetime benefit under the Plan
• you (or your dependent) fail to make required contributions for coverage
• any other disqualifications for benefits

Under certain circumstances, you and your covered dependents may be eligible to purchase continuing coverage for a limited time.

Certificate of Coverage

When your coverage under the Lumenos plan ends, you will receive a certificate of group health plan coverage on behalf of your employer. You may take this certificate to another health care plan to receive credit for your coverage with the company. You will only need to do this if the other health care plan has a pre-existing condition limit. Coverage under the Plan will not be considered by another plan if the coverage is followed by a break in coverage of 63 days or more.

Coverage Under Special Circumstances

Under certain circumstances, even if you are not employed, you may be able to continue coverage under the Plan. Your account will continue to be available to you while you are covered during these circumstances.

For more information, see:

• If You Take a Military Leave of Absence
• If You Take a Family Medical Leave Absence (FMLA)

If You Take a Military Leave of Absence

If you are on a military leave of absence under the Uniformed Services Employment and Reemployment Rights Act (USERRA), you and your dependents may continue to receive medical benefits under the Plan for a limited period of time, as long as you pay any required premiums (See the COBRA section for information concerning your rights and obligations to continued coverage).

You will receive benefits during your USERRA leave until the earlier of the following:

• the day after the date your leave ends, if you fail to return to employment
• 24 months from the date your USERRA leave began.

During your USERRA leave, you can pay your contributions for medical coverage on a monthly basis to the company. If your length of USERRA leave is less than 31 days, then your contribution amount will be the same as the active employee rate. However, if your length of leave is 31 days or longer, then your contribution amount will be up to 102% of the cost of your coverage.

If You Take a Family Medical Leave Absence (FMLA)

If the company grants you an approved FMLA leave, coverage continues during your approved leave as long as you continue to pay your required contributions. If you take paid FMLA leave, your premiums continue to be taken out of your paycheck. If you take unpaid FMLA leave, you can prepay your premiums or remit payment on an after-tax monthly basis. Coverage will not continue beyond the earliest date on which:

• you fail to make any required contribution
• the company determines your approved FMLA leave is terminated
• you are no longer eligible for coverage.

If you return to active employment after your FMLA leave is over and didn't maintain your coverage during the leave, your coverage can be resumed with no waiting period. However, you must make a request for this coverage within 31 days of when the company determined your leave was over. If you do not make this request within 31 days, coverage is not available until the next open enrollment period.

Right to Continuation Coverage

You have the right to COBRA continuation coverage if you lose coverage under the Plan as a result of a termination of employment (for reasons other than gross misconduct) or a reduction in your hours of employment.

Your spouse has the right to COBRA continuation coverage under the Plan if your spouse loses coverage under the Plan as a result of any one of the following four events:

• you terminate employment (for reasons other than gross misconduct) or have a reduction in your hours of employment (including a military leave of absence)
• you die
• you and your spouse divorce or legally separate
• you become entitled to Medicare

Your covered dependent children may have the right to COBRA continuation coverage under the Lumenos plan if your dependent children lose coverage as a result of any one of the following five events:

• you terminate employment or have a reduction in your hours of employment
• you die
• you and your spouse divorce or legally separate
• you become entitled to Medicare
• your dependent child ceases to be an eligible dependent under the Plan

These events that result in a loss of coverage are called "qualifying events." You, your covered spouse, and your covered dependents that are covered immediately preceding the qualifying event are called "qualified beneficiaries". A child born to or adopted by (including a child placed for adoption with) a covered employee during the covered employee's COBRA period is also considered a "qualified beneficiary" if properly enrolled.

Notice and Election Rules

The Plan Administrator must send notice to qualified beneficiaries of the right to the continuing participation following the covered employee's termination of employment, reduction in hours or death.

If the covered spouse and/or covered dependent children lose coverage as a result of a divorce, legal separation, or dependent child ceasing to be a dependent, you or the affected qualified beneficiary must send notice to the Plan Administrator within 60 days of the latter of the event or the date coverage is lost as a result of such event. The Qualified Beneficiary will then be sent a notice of this right to continuing participation following receipt of your notice.

Once you and/or any other qualified beneficiary have been provided notice of the right to elect COBRA continuation coverage, an election for continuation coverage under the Plan must be made within 60 days of the later of the date of the notice or the date coverage is lost as a result of the qualifying event. If a qualified beneficiary fails to provide this notice to the Plan Administrator during this 60-day notice period, the qualified beneficiary will lose the right to COBRA continuation coverage and coverage under the Plan will cease as of the last date the dependent was eligible for coverage. Each qualified beneficiary has a separate and independent right to elect COBRA continuation coverage. A qualified beneficiary employee or spouse can elect coverage for any other qualified beneficiary. On the other hand, you may not decline COBRA continuation coverage for the qualified beneficiary spouse. A parent or guardian can elect coverage for a qualified beneficiary child who is a minor.