Search the Community

Under Section 1.125-4(e) a mid year change is permitted when an employee or spouse "Becomes entitled to coverage (i.e. becomes enrolled)" in Medicare Part A or Part B. If an employee does not actually enroll in Medicare when first eligible, does the actual enrollment in a mid-year in a later year (say beyond age 70) qualify as a change permitting him to drop health care under the employer plan? Premiums are paid pre-tax under the cafeteria plan. I am wondering what the purpose of the parenthetical in the regs is and will it help this employee who has now decided he wants to enroll in Medicare, but he won't be covered in time for start of the plan year.

I was released from a large company on 8/31/13 and offered COBRA coverage accordingly. None of the notifications or the plan summary description make mention of a need for my 67 year old husband to become entitled to (sign up for) Medicare part B to receive identical coverage. In our coverage the day before I was released, he did not have Medicare B. At the end of December we learned my husband would need surgery. The first week of January, I called the provider to verify our coverage & maximum out of pocket for him. The reply I received that day was in line with what I understood our existing coverage to be. I called again a few weeks later to see why claims weren't being paid as usual. I disclosed that we were COBRA and that he had Medicare part A, but not part B. I was told that they would resubmit for payment, it would take 30 days. I called several times to monitor status on this. Until 3/11, the answers were that it was in process, it would be 30 days. After 30 days was up, the answer was that review was complete and that it would take an additional 30 days for full correction. Last Tuesday, on 3/11/14, I was informed that because he is "eligible" for Medicare, they will only be paying 20% rather than filling the gap for part B. He is indeed eligible for part B, but he is not entitled to part B. Since he was under my insurance plan 2 years ago when he became eligible, he declined, so is not entitled. Nevertheless, his coverage has changed from the day before I was terminated to a 20% limit. There is no indication of this possibility in any of the COBRA documentation or summery plan description. I have been searching for information on COBRA & Medicare. My understanding of the law is that it pertains to entitlement, not eligibility. If he had signed up for Part B, he would be entitled. Since he didn't, he is only eligible. I've talked with both the company (self insured) and the carrier about this. They are both sticking to the "eligibility" status as reason for declining coverage now although there has been a variety of answers to this from both of them. The first surgery was double hernia on 1/10/14 after my initial call to the carrier. During pre-op workup, we discovered he had a large dissected aneurysm and leaking valve. He had open heart surgery on 2/10/14. We are now being informed we are responsible for a gap mounting into tens of thousands of dollars. I think they are confused about entitlement vs eligibility. The last company rep I talked to said there have been other cases like this. My questions are: Is there a COBRA exclusion that allows them to require Medicare B entitlement or a change in coverage like this? If not, what recourse do I have? If there is a COBRA exclusion that makes this legal, do I have recourse with the carrier who gave me incorrect information for 2 months while we incurred extensive medical bills? Thank you, Sue B