COBRA

[Guest JD698]

An Individual who elected cobra, whose coverage terminated 7/31 intends to pay premium in a week's time is scheduled for surgery before the premium will be paid. This is a self insured plan. As hospital will not do the surgery (heart surgery, non emergent), does the plan have to guarantee benefits prior to payment or can it advise the medical provider that if the premium is paid there will be coverage but if the premium is not paid, then the procedure will not be covered???

[Guest chloe]

You can't guarantee coverage because you can't be sure that the premium will be paid by the end of the grace period. The federal regulations do not require you to guarantee coverage, but they do require that you give a complete response to the provider. So, you need to tell them something to the effect of the service is a covered expense, pending payment of the COBRA premium. But you should be careful not to guarantee that the service will be covered even if the premium is paid because it could turn out that the surgery doesn't meet medical necessity requirements, its an out of network provider, or some other exclusion or limitation may come into play.