Sandra Pearce

I have yet a different question. Since reinsurance is purchased using the plan document and the coverage provided by the Plan, why is the reinsurer taking the position that they will not reimburse this specific drug? Is your self-insured plan allowing an expense that is not really covered by the Plan, such as an experimental drug, to be paid by the Plan. In that case the real answer may be that you are paying claims for services (drugs) not covered in your Plan.

When group term life insurance is paid for pre-tax the insurance becomes employer "paid" group term life insurance and any benefit in excess of $50,000 (including other employer paid group term life insurance) is taxable to to the employee using the IRS tables.

We have this provision in our Plan: If a full-time student subsequently drops below the minimum number of credit hours during a semester, coverage will continue until the beginning of the next school semester. A Dependent enrolled full-time in school will be covered until the beginning of the said next semester (i.e., covered through summer break), unless graduation occurs.

Maybe you could print the new notice regulations and highlight the applicable timing violations.

Also, remember there are tax implications for the employee on any employer paid group term life in excess of $50,000.

What were you told was inconsistent about dropping coverage for a dependent who has become newly eligible for other coverage?

The model General Notice provided in the final regulation reads: [Enter name of group health plan and name (or position), address and phone number of party or parties from whom information about the plan and COBRA continuation coverage can be obtained on request.] We only have one plan and the employer company is the Plan Sponsor and Plan Administrator (self funded). If we had more than one option I believe as Plan Sponsor we could put the name of the employer sponsoring company down and the contact at the employer company. In my case that is me since I handle COBRA for our company. Just a suggestion.

I don't think that the number of dependents would have anything to do with Special Enrollment provisions in a health plan; however, if the child came in to the U.S. from a country with socialized medicine like the U.K. or Australia, or had other coverage in another country that was lost because the child left the country then I could see that as a loss of other coverage which would fall under the Special Enrollmlent provisions of HIPAA.

Our Health Plan (self funded) has never had an open enrollment. This was a decision we made when we were no longer able to use underwriting for late entrants. We do of course follow the rules for HIPAA Special Enrollments. Someone electing to pay for their coverage under our Section 125 Plan has the ability to stop pre-taxing at the Section 125 Plan open enrollment (1/1) and therefore drop out of our health plan, but they do not have the ability to use the 125 Plan open enrollment as an avenue into our health plan, because the underlying health plan does not allow for entry after initial eligibility except when the HIPAA Special Enrollment provisions apply or when court order (QMCSO).

The COBRA regulations specifically state that the QB must be determined disabled by the SSA under Title II or Title XVI. Here is what I found on the SSA's own web site regarding claims for disability benefits: Q. Who can get disability benefits under Social Security? A. Under the Social Security disability insurance program (title II of the Act), there are three basic categories of individuals who can qualify for benefits on the basis of disability: - A disabled insured worker under 65. - A person disabled since childhood (before age 22) who is a dependent of a deceased insured parent or a parent entitled to title II disability or retirement benefits. - A disabled widow or widower, age 50-60 if the deceased spouse was insured under Social Security. Under title XVI, or SSI, there are two basic categories under which a financially needy person can get payments on the basis of disability: - An adult age 18 or over who is disabled. - A child (under age 18) who is disabled. Since the former employee does not qualify by virtue of disability for a determination from the SSA, I would say he does not qualify for the extension. I doubt that any insurance company would reduce the requirement for disability detemrination by SSA.

No federal requirement for an annual open enrollment. HIPAA requires Special Enrollment provisions.

Our Business Travel Accident coverage has a War Risk rider and with notification to the carrier of travel, and possible additional premiums we have coverage for travel in war risk countries. Example would be a recent trip by an employee to Algeria. Six days of coverage for $203. Our benefit is $200,000.

I would have an attorney review the domestic relations order your plan has been served with. First, many states do not have Legal Separations. Possibly, the order you have been served with is just to prevent the employee from dropping the spouse in lieu of the pending divorce. Again, I would have an attorney review the document. With all that said, if the person is legally separated and if your Plan Document clearly states that legal separation is a COBRA qualifying event, I would send a COBRA notice to the spouse and terminate coverage.

Many times a parent gives physical custody of a child to a family member in order to allow the child to go to a particular school and along with physical custody authorizes the family member to direct any medical treatment during the period of physical custody. That type of custody would not make the child an eligible dependent in our health plan. Our plan document includes in dependent eligibility "grandchild, child subject to the Employee’s (or spouse’s) legal guardianship." We would only allow this person to be added if the employee had legal guardianship of the child. In cases where we have been unsure of the documentation we have requested the advice of legal counsel.

Our plan would reimburse from the previous year's account (the year in which the medical expense was incurred) if there was sufficient documentation to show that a determination of employee cost could not be made before now AND if the employee had notified the plan of this prior to the normal claim filing deadline. We would not reimburse from this year's plan.

Our plan only allows entry when loss of coverage is due to loss of eligibility for the coverage; therefore, we require a copy of the COBRA offer or a letter from the (former) employer stating the coverage was lost due to termination of employment, reduction of hours or loss of dependency status, etc.

COBRA qualified beneficiaries are treated the same as active employees in the employer sponsored plan. Open enrollment and new plan design would have an affect on both.

Couldn't the new plan could also be disqualified for accepting a rollover that included after tax dollars? The original post stated that the person put $2,000 into the IRA after it was rolled from the prior 401k plan.

The regulations speak of revoking elections due to leave. I don't see anything that would allow this change unless there was an open enrollment during the leave.

Could you give an example of what you mean by reduce the benefit?

This is a copy of that Q&A: Q-3: When may a plan terminate a qualified beneficiary's COBRA continuation coverage due to the qualified beneficiary's entitlement to Medicare benefits? A-3: (a) If a qualified beneficiary first becomes entitled to Medicare benefits under Title XVIII of the Social Security Act (42 U.S.C. 1395-1395ggg) after the date on which COBRA continuation coverage is elected for the qualified beneficiary, then the plan may terminate the qualified beneficiary's COBRA continuation coverage upon the date on which the qualified beneficiary becomes so entitled. By contrast, if a qualified beneficiary first becomes entitled to Medicare benefits on or before the date that COBRA continuation coverage is elected, then the qualified beneficiary's entitlement to Medicare benefits cannot be a basis for terminating the qualified beneficiary's COBRA continuation coverage. (b) A qualified beneficiary becomes entitled to Medicare benefits upon the effective date of enrollment in either part A or B, whichever occurs earlier. Thus, merely being eligible to enroll in Medicare does not constitute being entitled to Medicare benefits.

Long Term Care insurance is not eligible under a 125 plan.

Our self-insured plan excludes: Treatment due to an injury or illness, which arises out of, or in the course of, employment or occupation for remuneration or profit; or for services covered in whole or in part by Workers Compensation laws and/or services rendered as a result of occupational disease or injury.

I would consider it a 2003 expense if the expense would have been incurred even if the stay had only been a day or two in November 2003. The fact that the stay continued until 2004 seems irrelevant to me.

The retirement or termination of employment is of course a qualifying event; however, if the retiree can continue existing coverage as a Retiree and that status allows the Retiree to carry the employer coverage until age 65, Medicare eligibility, then I would say that the COBRA qualifying event would be the loss of coverage as a Retiree at 65. This is the way we handle Retirees in our health plan.