COBRA and overage dependents

[Guest jugroad]

We have a dependent student who has reached the limiting dependent age (age 25), but who is still attending school.

This plan includes the use of a PPO. Since dependent students, who live outside of the PPO service area, cannot reasonably utilize the network, there is a specific benefit that states that Dependent full-time Students who reside outside of the Network service area while attending school will receive the Network level, rather than the non-network level of benefits for their claims.

This dependent has elected COBRA and is still living outside of the PPO service area. We received claims for an injury (again, outside of the PPO service area, therefore non-network). The question is - Does this COBRA participant still receive the in-network benefit that is reserved for "dependent full-time students" or would they receive the non-network benefit level since they are technically no longer a "dependent full-time student" under the definitions of the plan?

On one hand the Regs talk about QB's having the same status as active employees (therefore not eligible for this class of benefits) , on the other hand there is language concering "similarly situated non-COBRA beneficiaries."

Any thoughts?

[mroberts]

This is going to be determined by the plan document. Most PPO's do not allow employees or dependents to go out-of-network and have claims reimbursed as if they were in-network ones.

Since the dependent is no longer a full-time student by the plan's definition, what does the contract or SPD say about an employee or any other dependent that goes out-of-network?