Can they actually Say I am on COBRA, I dont't think so! HELP!?!?!

[Guest TROSE05]

HI... hopefully someone can give me some insight on my situation, I got hurt on the job back in September 04..... Went out on Medical Leave in December 04.......The way they have it set up I still get a paycheck every 2 weeks from my company for full pay... but I pay my own premium for my benefits..... and the company still pays their portion of the premium.....Well about 2 weeks ago, I got a bill in the mail for my insurance premium, and on it said that as of March 13, 2005 I had been switiched over to COBRA continuatin coverage... mind you my premium is still what it always has been, has not gone up any... is $142.00 a month... from what I have been told when you go on COBRA continuation coverage your premium at minimum usually doubles...... I am not out on Short Term Disabiity or Long Term Disability.......have not been terminated, or do not stand to loose my job.... I will return to my job as soon as my doctor releases me......Now with all this said.....

How can they say I am on COBRA????

With all that said... if you need ask any further questions, please feel free...

Thank you...

[Mary C]

According to the regulations, the most the COBRA participant can be charged is the entire premium plus a 2% administration fee. However, the company is free to charge a lower amount or no amount if they so wish as long as they charge this lower amount in a non-discriminatory manner. The Company is also free to set policy when active coverage ends and COBRA begins when the employee is on leave subject to other government regulations, such as FMLA.

For example, when we layoff someone due to job elimination we offer 3-6 months company paid COBRA depending on their length of service. The COBRA participant does not pay for COBRA coverage until their 3-6 month period runs out.

A call to you local human resource department or benefit department can clear things up, but from the dates in your post, it appears that your medical coverage remained active while you were on the 12 week FMLA period, but that at the end of that time in March, your coverage changed to COBRA, and the company is picking up a portion of your COBRA premium.

[jsb]

You didn't indicate which state you are in. Workers' comp laws can vary significantly between states. This could include what the employer's responsibility (under the law) is for maintaining health insurance for you while you are not working due to an on the job injury.

Here's the good news! Sounds like your company is treating you right! You're hurt and not working and still have health insurance. You're not paying any more than you did while you working. Be thankful that your company takes its responsibilities to its injured employees to heart.

Your company is also (responsibly) protecting itself. Workers' comp claims can go on and on and on, and they need to try to limit their liability. COBRA generally provides for 18 months of continuation coverage. By triggering your COBRA period, they are seeking to limit their liability to the 18 months required by law. Ultimately, the company may provide benefits under their policy or State law for a longer period due to your industrial injury.

Some workers' comp claims are not legitimate or get exaggerated. If yours is totally on the up-and-up, I think you can expect your company to treat you right and help you get back to work. So far, it sounds like they are doing all the right things. As above, you should be thankful that you work for a good outfit.

[Guest TROSE05]

According to the regulations, the most the COBRA participant can be charged is the entire premium plus a 2% administration fee.  However, the company is free to charge a lower amount or no amount if they so wish as long as they charge this lower amount in a non-discriminatory manner.  The Company is also free to set policy when active coverage ends and COBRA begins when the employee is on leave subject to other government regulations, such as FMLA.

For example, when we layoff someone due to job elimination we offer 3-6 months company paid COBRA depending on their length of service.  The COBRA participant does not pay for COBRA coverage until their 3-6 month period runs out. 

A call to you local human resource department or benefit department can clear things up, but from the dates in your post, it appears that your medical coverage remained active while you were on the 12 week FMLA period, but that at the end of that time in March, your coverage changed to COBRA, and the company is picking up a portion of your COBRA premium.

Actually I did call my HR dept, and they couldnt tell me anything, and The Benefits dept are the ones telling me all the stuff I wrote about the COBRA....

I called my benefits people this morning and ask them how they could say I am on COBRA and they basically said..."You aren't technically on COBRA, But you are" How much sense does that make??

What they said is..... I am not technically on COBRA, but as they put it my COBRA CLOCK has started, it IS NOT somehting mandated by the federal law but they said it is just something the company does on their own..... When you go out on leave, Mine being on Workmans Comp Medical Leave, basically after your 12 Week FMLA , they start your COBRA CLOCK.... technically I dont get 18 months continuation, from if my employment ends for COBRA according to them, I get 18 months from the day my "COBRA CLOCK "started....But they never could really give me a good explaination, they just kept saying, that how we do it, and your "COBRA CLOCK" has started.

Can they really do this? Since it is not something mandated by the federal law??

My partner was out on Medical leave from April 5, 2004 until April 5, 2005, and they did not start her COBRA until April 6, 2005 One year after she went out on Medical Leave....because company policy says, after 1 year of medical leave your employment will automatically terminate.... So on her 1 year out they terminated her employment and the next day they started her COBRA, she didnt even get 60 days to opt for it, and the 45 day period to pay for it. which I have read about in the COBRA COVERAGE federal laws and regulations....

The company HR did tell me that IF I am out a year, that my employment most likely will not terminate, they will probably extend it another year, because I am out on a work related injury, and they said they can not terminate me, but if I am out 2 years, then at the end of that time, they can terminate me, and offer me a settlement, but according to my benefits people, I will not get offered COBRA becaue they say my COBRA will expire before, that time.....

How can they make their own rules to COBRA, I thought thats what the Federal Laws and regulations were for.!?!??!

[Guest TROSE05]

You didn't indicate which state you are in. Workers' comp laws can vary significantly between states. This could include what the employer's responsibility (under the law) is for maintaining health insurance for you while you are not working due to an on the job injury.

Here's the good news! Sounds like your company is treating you right! You're hurt and not working and still have health insurance. You're not paying any more than you did while you working. Be thankful that your company takes its responsibilities to its injured employees to heart.

Your company is also (responsibly) protecting itself. Workers' comp claims can go on and on and on, and they need to try to limit their liability. COBRA generally provides for 18 months of continuation coverage. By triggering your COBRA period, they are seeking to limit their liability to the 18 months required by law. Ultimately, the company may provide benefits under their policy or State law for a longer period due to your industrial injury.

Some workers' comp claims are not legitimate or get exaggerated. If yours is totally on the up-and-up, I think you can expect your company to treat you right and help you get back to work. So far, it sounds like they are doing all the right things. As above, you should be thankful that you work for a good outfit.

I live in Texas....

How can they go ahead and trigger my COBRA coverage? I have only been out 5 months....

According to our company Policy, If an employee is out for 1 year on medical leave, at the end of that year, your employment will be terminated.....but they have said, since mine is a work related injury, mine will run 2 years.. then I will be terminated, and offered a settlement, but the benefits people that handle out benefits and such, have said that I will not be offered the 18 month Continuation Coverage, that Federal Law mandates, because they have already started my COBRA and by that time they say it will have run out.....So I will be SOL on that issue....

When ask though, they say..."You arent technically on COBRA, but you are" How dumb is that? They say my so called "COBRA CLOCK" has started..... this is something the company does on their own, at the end of your 12 week FMLA period, they start your COBRA CLOCK, and what they do is each month or so they raise your premium a little more..... and my 18 months of coverage started at the end of my FMLA.... and will go 18 months from there.... not 18 months from the end of my employment.... I thought i was also supposed to get 60 days from the end of my employment to opt for COBRA and also get 45 days to pay the premium, atleast thats what the federal law says....

My partner was out from April 5, 2004 to April 5, 2005 on April 6, 2005 they automatically started her COBRA Continuation coverage.... her premium jumped from $62.00 a month to 286.00 a month....she did not get the 60 days to opt or the Coverage....or 45 days to pay her premium either..

Whats the purpose for Federal Laws and regulations mandating these things if the company can make their own rules.... and do whatever they darn well please..

My workers comp issue is definately on the up and up... I herniated several discs in my neck lifting something extremely heavy..... weighted probably 100 lbs or more... lost my balance and it hit my head, wrenched my neck and herniated the discs.... already had one surgery... possibly looking at a second.... and this is all been ordered by the "workers comp doctors."

[oriecat]

I think your benefits people did a very poor job of explaining and probably caused more confusion than they should have. Termination is not the only qualifying event that triggers COBRA coverage. There is also the qualifying event of reduction of hours, so that you are no longer eligible for the plan. As a non-working employee, you are probably not eligible under the group health plan any longer (most plans require employees to be actively working a certain # of hours each week or month). FMLA coverage does not count towards that, so you are still considered an active employee while on FMLA, but once your FMLA is used up, so you are technically not an active employee and therefore not eligible for the plan. Thus, you have to be put on COBRA or you would need to be removed from the plan all together.

Regarding your partner - all plans can be written with different terms. So perhaps her employer has a special clause that allows them to offer the one year of medical leave, or perhaps they were just in violation of their plan.

[Guest TROSE05]

I think your benefits people did a very poor job of explaining and probably caused more confusion than they should have.  Termination is not the only qualifying event that triggers COBRA coverage.  There is also the qualifying event of reduction of hours, so that you are no longer eligible for the plan.  As a non-working employee, you are probably not eligible under the group health plan any longer (most plans require employees to be actively working a certain # of hours each week or month).  FMLA coverage does not count towards that, so you are still considered an active employee while on FMLA, but once your FMLA is used up, so you are technically not an active employee and therefore not eligible for the plan.  Thus, you have to be put on COBRA or you would need to be removed from the plan all together.

Regarding your partner - all plans can be written with different terms.  So perhaps her employer has a special clause that allows them to offer the one year of medical leave, or perhaps they were just in violation of their plan.

We work for the same company

And you are right about the reduction In Hours ......The laws and regulations satate that reduction in hours is dropping from full time to part time hours which would keep you from qualifying for benefits.

Also we called the Texas Dept of Insurance and they have never heard of the whole COBRA CLOCK thing and also talked to the Texas Labor Board, and neither have they.

[Guest georgia]

you might contact the state of Texas Insurance Commissioner's Office and the Worker's Comp Board. they should have the inside track on your particular situation and how it differs from your partners situation.

[oriecat]

Well that wasn't clear from your post. Maybe they have realized that they have been violating the plan and are attempting to correct their mistakes. We can't know that. Did you ask them why the discrepancy in treatment?

[Mary C]

I agree with Oriecat that you got a poor explanation, but no one on this board can explain it any better because we do not have the information your human resource department and benefit department is working with nor do we have knowledge of your company's policies and procedures. While you and your partner may work for the same company, company policy and government regulations may have changed since your partner began her leave and when you began your leave. Also, the worker's comp laws may mandate how your coverage is handled in Texas. All three sets of regs, COBRA, FMLA and Workers Comp, need to be taken into consideration. And the size of your company - the number of employees has an impact on whether we're talking Federal COBRA or state mandated continuation of coverage.

But I can tell you, the Company can set policies on when to terminate active coverage (and a lot of companies do terminate active coverage at the end of an FMLA leave allotment) and for the company to decide whether to charge you the entire amount of premium or subsidize it.

[david rigby]

Does this help? http://www.dol.gov/ebsa/faqs/faq_consumer_cobra.html

[jsb]

Troseo,

Take 3 deep breaths and relax. For the time being, you have your health insurance coverage and should focus on getting your health back. I hope that your recovery goes well and you are able to return to normal functioning.

If you never return to work, will you have a disability retirement through your employer's pension plan, or would you have to rely on social security disability? If you would have to rely on social security disability or other pension, would you be able to afford the full (102%) cost of your employer's COBRA coverage or would you be dropping the coverage anyway?

It sounds like your employer is going to continue to keep you covered for now. This is a good thing. My recommendation is to wait and see how they will handle things if you are never able to return to work. Depending on what they do at that time, you may have other options or recourse.

Good luck. I hope you make a speedy recovery and everything works out for you.

[Guest TROSE05]

Hey all thanks for the replies......Anyway

I checked with the company that I have my group coverage with, well or atleast my COBRA coverage now... to see if they would cover me under a individual plan or roll me over to one or something.... they acutally gave me a pretty good price.... but I did notice in their brochure that it said under "Pre -Existing Conditions"......

Preexisting conditions will not be covered during the first 12 months after an individual becomes a covered person. This exclusion will not apply to conditions which are both: (a) fully disclosed to (the insurance company) in the individual’s application; and (b) not excluded or limited by our underwriters.

The way I am understanding this is, basically if I am honest with them on my application and tell them about my herniated disc, and my surgery that they will not exlcude it as a pre existing condition... Am I right??

Also is it true that the HIPAA law says that a insurance company can not deny you coverage, for a pre existing condition if you have not had a lapse in coverage for 63 days or more? Which I have not had..... becaue I am still on my COBRA .....Also I am getting a certificate of creditable coverage from my insurance company....

You would also be surprised the insurance people that have no idea what you are talking about when you mention the HIPPA law and what it states about pre existing conditions.

Whatever input you can give me I would appreciate...

Thanks Ya'll

TRose

[Steve72]

I agree that you didn't get a very good explanation.

What it SOUNDS like is happening from the "COBRA clock" comment, is that they have started your 18 month COBRA period, but are continuing to pay the employer portion of the coverage (I think this is what they mean by "on COBRA but really not"). The COBRA coverage is the same group coverage you had as an employee. The practical impact of this, however, is that you will be able to access COBRA for a shorter period than if your "COBRA clock" had started to run at termination.

As for the pre-existing condition exclusion, that rule applies to GROUP coverage, not individual coverage. Unfortunately, an individual policy can impose a pre-existing condition exclusion on you (unless limited by state law).

There is a guaranteed access provision in HIPAA, which means, as you say, that you can't be turned down for individual coverage...but it doesn't set limits on how high they can price the premium.

[Guest TROSE05]

Hi Steve...

Thanks for the reply.....

I see what you are saying about the COBRA CLOCK thing....but as for the existing condition exclusion that I talked about in my post,...Where I said that they say if you are honest about your condition they will exclude the condition as pre existing........ that is for individual policys under the company that I have my COBRA with, but with an individual policy.....

Also I was looking last night and reading about the HIPAA law.... and I also read where under the HIPAA law, says....The law provides that the longest allowable time period that newly covered members may be subject to the pre existing limitation is 12 months, The 12 month pre existing limitation, is reduced for each month that the claiment had Insurance coverage or group plan from another source within 63 days prior.

As for the company putting their own price on the policy..I understand that as well, and have already had experience with that........ I got a price of 186.00 a month on the policy I am applying for...Through this individual policy..... so that is much much better then the COBRA price I am paying.

Now I just have to send them my first months premium and get the ball rolling...

Thanks Again

[Steve72]

Also I was looking last night and reading about the HIPAA law.... and I also read where under the HIPAA law, says....The law provides that the longest allowable time period that newly covered members may be subject to the pre existing limitation is 12 months, The 12 month pre existing limitation, is reduced for each month that the claiment had Insurance coverage or group plan from another source within 63 days prior.

HIPAA does say this, but that rule does not apply to an individual insurance policy. The rule only applies to group policies.

If you switch to an individual policy, and they exclude treatments for a pre-ex, the exclusion will not be subject to the HIPAA limitations you describe.

[Guest SKC1959]

I have a situation with cobra, it is a bit different from what has been discussed so far on this board, but I was on cobra, and my partner was going to add me to her health benefits, since our company started to offer domestic partner benefits, the cobra was getting way to expensive for me to pay, so my partner called and talked to whomever is responsible for her benefits enrollment or changes whatever, well when she called and talked to them, they told her NOT to pay the premium on my cobra, then to call back before the end of the month, and tell a rep that she wanted to include me on her health benefits, because it is a qualifying status change, Well we did exactly as the rep said to do, got her name and everything, so we did not pay my premium, and we called back just as told to, to have me put on her benefits, well when we called back, we explained what the other rep had told us, gave her name and all, Well, the rep we spoke to said... OH NO! you can not do that, you can not add your partner, So my partern ask why, again told them what the other rep had said etc....... well they proceeded to tell my partner that she could not add me to her benefits because she is on cobra as well, and that federal law does not allow same sex domestic partnership, Well the rep we had talked to had been told MANY MANY times and my partner ask MANY MANY times eventhough she is on cobra, could she still add me to her benefits, and this lady kept saying YES!!

So my question is, What can we do? because now my cobra stands to be cancelled because they want 870.00 before June 6 which we dont have.... I have checked into individual policys....and checked in to something called ,hipaa??, and found something under it that says.....

What if I am unable to obtain new group health plan coverage?

You may be able to purchase an individual insurance policy. HIPAA guarantees access to individual policies to eligible individuals. Eligible individuals:

*

Have had coverage for a least 18 months without a significant break in coverage where the most recent period of coverage was under a group health plan

*

Did not have their group coverage terminated because of fraud or nonpayment of premiums

*

Are ineligible for COBRA continuation coverage or if offered COBRA continuation coverage (or continuation coverage under a similar state program), have both elected and exhausted their continuation coverage

I basically according to this am eligible except for the part that talks about non payment... Well, my issue is do to being misinformed by the company benefits reps...we have ordered them to check the recorded phone call with the rep that told us this.... and they have said, at best, if the call shows that the rep gave us the wrong info, they will not cancel my Cobra and we will have to pay the 870.00 by june 6.......... Any idea on what we can do about this????????????

Thanks

S

[jsb]

It is very unfortunate that you were apparently given bad information. You might go back to them and ask again why you cannot be a "dependent" on your partner's coverage. This does not make you a "qualified beneficiary" under the COBRA laws, just a dependent of the qualified beneficiary. If you could have been covered as a dependent when your partner was working you should be able to be covered now.

But, I'm a bit confused by the premium issue. Surely there would be a cost to be added to your partner's coverage; probably just about as much as carrying your own coverage. Which leaves me a bit baffled why the premium amount ($870, which sounds like about 2 months worth of coverage) is causing you such heartburn. Seems you were paying for your own COBRA all along but then stopped in anticipation of this better deal. I gather you did not set this money aside but must have spent it elsewhere, which now creates the problem with the $870 payment. Not very good planning.

Generally, voluntary non-payment of premium is not a qualifying event. End of a COBRA qualifying period is. The employer's open enrollment period might offer another opportunity to make a plan change. I would recommend figuring out how to come up with the premium money so you can continue your own COBRA coverage. Once this is back on track, you can safely evaluate your other options.

[Guest SKC1959]

Yep, I spent the money to pay rent! Damn! What a terrible thing to do, and you bet your Ass the $870.00 amount is giving me heartburn as you put it, That $870.00 was one lump sum they sent me, it was not bill after bill piling up, Hey! I have an idea, you can give me the money. I should have known better then to come to one of these places for any information, as usual you dont get much help, only someone who wants to be a wise guy. Thats the last thing I need. I am dealing with enough in my life.

Thanks for nothing.

Moderator you can canel my membership to these boards to as far as I am concerned.

[Guest Pensions in Paradise]

jsb - for what its worth, I didn't get the impression that you wanted to be a "wise guy". In fact, I thought your post was very helpful. But obviously SKC1959 thinks otherwise. Sometimes people don't like being told the truth.

[oriecat]

No doubt. I too thought it was a good post.

[jsb]

SKC - Sorry you took my post so badly. Perhaps there is some additional information here that will be useful.

So they gave you bad information. And I understand that you are angry about it. But what should be the penalty? How have you been damaged by this other than some unmet hope for a better deal? As a plan administrator, I would try to get you back into the same position you would have been in had no mistake had been made; not better or worse, back to the same. This would mean undoing your cancellation and offering you a chance to continue your COBRA coverage.

This is apparently what they have done. But this includes your having to pay the premium that you should have paid...which is also what they are asking you to do. If they are admitting their mistake, perhaps they will let you pick-up the missed payments over a reasonable time period.

It seems that you want someone to say you have a great case and should go get a lawyer and sue the bums. But first there must be harm. How have you been harmed by their actions? You didn't get coverage under your partner due to the bad info, which has been corrected. Disappointing that you didn't get the coverage, but not harm. They are offering to set you back up under your own COBRA, which you cancelled, in exchange for the premiums you would have paid anyway. Expensive, but not harm; they are seeking to do the right thing. Sorry, but as I see it, there doesn't appear to be any kind of actionable claim. But then, I'm not an attorney, so perhaps you should go talk to a couple of them in your local area who specialize in this kind of thing. They can tell you for sure if you have any kind of case they can win for you.

So what options do you have?

1) Pay the money to have your coverage reinstated. (Maybe try to negotiate the payment of the lump sum over some reasonable time.)

2) Find cheaper coverage and buy that instead. (If you have chronic medical conditions this may not be possible without significant exclusions, but you might be able to get cheaper coverage than a COBRA plan if you are generally healthy. Benefits will likely be different, but you can protect yourself against catastrophic events.)

3) Find out about the employer's open enrollment period and rules so that maybe you can be added to your partner's coverage at that time.

Good luck.