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Employee Benefits

20 E. Main St., Suite 600
Mesa, AZ 85201

Hours of Operation

M-Th 7am-6pm
Closed Fridays & Holidays

Contact Information

480-644-2299
benefits.info@mesaaz.gov

Important Forms

COBRA Enrollment Form

COBRA Initial Notice

Important Notices & Documents

Plan Document

COBRA Continuation of Coverage

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Fiesta District

The Consolidated Omnibus Budget Reconciliation Act (COBRA) allows you to continue coverage of medical, dental, vision and health FSA when coverage is lost for certain reasons, such as termination of employment, divorce, or loss of dependent status.



Eligibility

A variety of loss of coverage events make you eligible for up to 18 months of COBRA coverage, including:

  • You voluntarily leave the City
  • The City ends your employment for any reason, unless you were terminated because of gross misconduct
  • The number of hours you are scheduled to work at the City is reduced below that required for eligibility

In some cases, your covered dependents who lose coverage, can continue coverage up to 36 months, such as:

  • You get a divorce or become legally separated
  • You die
  • Your dependent child no longer qualifies as a covered dependent due to the attainment of the Plan's age limit (e.g. age out), unless they are permanently and totally *disabled.  

*For more information, please see the Disabled Adult Dependent area under the Eligibility section.

COBRA Qualifying Event
Causing Health Care Coverage to End
Duration of COBRA for Qualified Beneficiaries
Employee Spouse Child(ren)
Employee terminated (for other than gross misconduct)
18 months
18 months 18 months
Employee reduction in hours worked (making employee ineligible for the same coverage)
8 months 18 months 18 months
Employee dies
N/A 36 months
36 months
Employee becomes divorced or legally separated
N/A 36 months 36 months
Dependent Child ceases to have Dependent status
N/A N/A 36 months

If you and/or a covered family member experience a COBRA qualifying event and have a  loss of health coverage with the City of Mesa, the City will send a COBRA Continuation Coverage Election Notice to your address on file.  Please be sure your mailing address information is up-to-date.  Active employees can update their contact information in ESS.  Retirees and Dependents can update their contact information by completing and submitting a Retiree/Dependent Address Change Form.


How much does COBRA cost?

2017 COBRA Monthly Premium Rates

Medical/Rx Basic Choice Plan
Choice PPO Plan
Copay Choice Plan
Single $465.12 $581.40 $639.54
Family $1,035.30 $1,294.38 $1,561.62
Dental
Preventative Choice
Dental Choice
Dental Choice Plus
Single
$87.21
$96.90
$112.20
Family
$144.84
$173.40
$255.00
Vision Basic Vision Plan
Vision Plus Plan
 
Single $5.65
$9.66
 
Family $15.61
$26.62
 


Steps to elect COBRA coverage:

  1. Review your COBRA Continuation Coverage Election package.
  2. Submit the completed and signed COBRA Enrollment Form to the Employee Benefits Administration Office no later than 60 days after your City of Mesa coverage ends or within 60 days of the date of the COBRA Election package notification (whichever is later):

In Person:  
Via Mail:  
Email:
  
Employee Benefits Administration, 20 E Main St, Suite 600, Mesa, AZ 85201
Employee Benefits, PO Box 1466, Mesa, AZ 85211-1466
benefits.info@mesaaz.gov


Conversion and Portability Privileges 

If you lose eligibility for Life and AD&D insurance coverage with the City of Mesa, you may be eligible to continue your existing Basic, Supplemental and Dependent Life and AD&D Insurance coverage at individual rates under the Conversion and/or Portability provisions of the respective insurance policies.  You will not need to answer any medical questions or have a physical exam to convert or port any eligible coverage.

Application for Conversion

Conversion allows you to convert your existing term life and AD&D policies to individual whole life or accident policies directly with RSLI at your own expense.  You can convert Basic Life, AD&D and/or Supplemental Employee Life Insurance or Supplemental Spouse/Dependent Life Insurance when you lose this coverage for any reason (e.g. termination or retirement from employment, move to a non-benefit eligible position, spouse or dependent no longer eligible for coverage (divorce, age-out).

To convert your Basic and/or Supplemental Life Insurance:

  1. Determine your premiums using the Life Insurance Conversion Form
  2. Complete and submit the Life Insurance Conversion Form to the Employee Benefits Administration office, within 31 calendar days from your last day worked.
  3. Employee Benefits will complete "employer" verification section and forward the application to the insurance carrier for processing

To convert your AD&D Insurance:

  1. Determine your premiums using the AD&D Conversion Form
  2. Complete and submit the AD&D Conversion Form to the Employee Benefits Administration office, within 31 calendar days from your last day worked
  3. Employee Benefits will complete "employer" verification section and forward the application to the insurance carrier for processing

Application for Portability

Portability allows you and your covered dependents the option to continue the current existing amount of coverage insured under the Basic and Supplemental Employee/Dependent term-life insurance, up to an individual maximum of combined Basic and Supplemental Life insurance of $550,000 (whichever is less).  Unlike conversion, this portable coverage does not have a cash value and the rates you pay will increase as you age.  Portability coverage may continue until you or your spouse reach age 70 or your spouse or dependent children no longer meet the definition of a spouse or dependent child.  You are not eligible for portability of any amount you have elected for conversion.  Additionally, there are other circumstances when Portability does not apply (conversion only would apply):

  • Dependent child aging out of their Supplemental Life Insurance coverage
  • Spouse and/or children who are losing Supplemental Life Insurance coverage due to a divorce
  • Surviving spouse/dependent children who want to continue Supplemental Life Insurance coverage after employee death

To Port your Basic or Supplemental Term-Life Insurance:

  1. Determine your premiums using the Life Insurance Portability Form
  2. Complete and submit the Life Insurance Portability Form to the Employee Benefits Administration office, within 31 calendar days from your last day worked
  3. Employee Benefits will complete "employer" verification section and forward the application to the insurance carrier for processing

The Following Illustration Shows Conversion and Portability Rights Based on the Loss of Coverage Factor:

Basic Life and/or AD&D
Loss of Coverage Factor
Employee Spouse Child(ren)
Employee Termination/Retirement/Transfer to Non-Benefited Conversion or Portability N/A N/A
Supplemental Life Loss of Coverage Factor Employee Spouse Child(ren)
Employee Termination/Retirement/Transfer to Non-Benefited Conversion or Portability Conversion or Portability Conversion or Portability
Aged Out Dependent Child N/A N/A Conversion Only
Divorce N/A Conversion Only Conversion Only
Surviving Spouse/Dependent Child
N/A Conversion Only Conversion Only

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