COBRA, HIPPA and FMLA
What are the 6 types of "medical care" under COBRA?
(1) Inpatient/outpatient hospital care; (2) physician care (3) surgery and other major medical benefits; (4) prescription drugs (5) dental and (6) vision care.
There are 3 basic requirements that must be met in order for you to be entitled to elect COBRA continuation coverage, what are they?
(1) Your employer must offer COBRA coverage (i.e., (2) a qualifying event must occur (termination or reduction in hours, medicare, divorce, death, loss of dependent child coverage under the plan) and (3) you must be a qualified beneficiary (you, your spouse, your dependent child.)
What are the 5 protections the Affordable Care Act created?
(1) extending dependent coverage to age 26; (2) prohibiting pre-existing exclusions for children under 19; (3) banning lifetime limits on coverage for essential health benefits; (4) phasing out and elimination of annual limits on essential health benefits; (5) requiring group health plans to provide an easy-to-understand summary of the health plan's benefits and coverage.
What are the 6 qualifying events to trigger COBRA?
(1) termination not as a result of gross misconduct/ reduction in work hours; (2) employee b/cs entitled to Medicare; (3) Divorce or legal separation; (4) death of the employee and (5) loss of dependent child status under the plan. (6) employer's bankruptcy
The employer must notify the plan if the following 4 qualifying events occur:
(1) termination or reduction in hours; (2) death of the employee; (3) employee entitled to Medicare; (4) bankruptcy of the employer
What are the requirements for an employee to be eligible for the FMLA?
1. 1 year of employment 2. 1250 creditable hours of service 3. an employer w/ 50 or more employees
What 3 groups of employers must offer FMLA?
1. All public agencies, 2. all public and private elementary and secondary schools, and 3. companies with 50 or more employees.
The employee must notify the plan if the following 2 qualifying events occur:
1. Divorce, legal separation 2. a child's loss of dependent child status under the plan.
COBRA generally does not apply to which groups of employers?
1. Federal government, 2. churches and 3. certain church-related organizations.
***COBRA generally applies to which groups of employers?
1. Private employers with 20 or more employees, 2. state government, 3. local government. (NOT Federal Government)
What is the cost of Consolidated Omnibus Budget Reconciliation Act coverage?
100% plus 2% administrative fee.
If the qualifying event for COBRA is the employee is terminated for reasons other than gross misconduct or reduction in hours of employment, what is the maximum continuation coverage?
18 months, but this can be extended by 11 months for a total of 29 months if someone becomes disabled and can be extended for 18 months due to the occurrence of a second qualifying event.
If the qualifying event for COBRA is death of the employee, what is the maximum continuation coverage?
36 months
If the qualifying event for COBRA is divorce or legal separation, what is the maximum continuation coverage?
36 months
If the qualifying event for COBRA is the loss of "dependent child" status under the plan, what is the maximum continuation coverage?
36 months
If the qualifying event for COBRA is the employee enrolls in Medicare, what is the maximum continuation coverage?
36 months.
Your initial COBRA premium payment must be paid by when?
45 days from the date you elect COBRA
What does the Consolidated Omnibus Budget Reconciliation Act require of most group health plan to provide?
A temporary continuation of group health coverage that otherwise might be terminated.
What is the Health Coverage Tax Credit (HCTC)?
An advanceable, refundable tax credit for up to 72.5 % of the premiums for COBRA if you lost your job as a result of international trade AND you qualify for Trade Adjustment Assistance (TAA).
Define "group health plan" under COBRA:
Any arrangement that an employer establishes to provide employees or their families with medical care, whether it is through insurance, HMO or private employer sponsored plan.
What does COBRA stand for?
Consolidated Omnibus Budget Reconciliation Act
If the qualifying event for COBRA is the employee is terminated for reasons other than gross misconduct or reduction in hours of employment, who are the qualified beneficiaries who can be entitled to elect continuation coverage?
Employee, spouse, dependent child
What does FMLA stand for?
Family and Medical Leave Act
It is a good idea to elect COBRA so that you can receive certain protections of HIPPA. What is the biggest protection?
HIPPA limits the length of any pre-existing condition exclusion that a group plan may impose and requires that any exclusion period be reduced by an individual's number of days of creditable coverage. COBRA is creditable coverage.
What does HCTC stand for?
Health Care Tax Credit
What does HIPPA stand for?
Health Insurance Portability and Accountability Act
If you accidentally short your payment, what happens to your coverage?
If the shortage is not significant, the plan must give you notice and 30 days to make it up.
Example: you are terminated from your employment, during the 18 month continuation of coverage period, you become eligible for medicare, what happens to your COBRA coverage?
It extends from 18 months to 36 months because a second qualifying event occurred.
What are the two types of insurance not recognized as medical care under COBRA?
Life and disability insurance.
What does the Family and Medical Leave Act (FMLA) require an EMPLOYER to do?
Maintain coverage under any group health plan for an employee on FMLA.
Is FMLA the same as COBRA?
No
Is taking FMLA a qualifying event for COBRA?
No
After the plan has been notified of a qualifying event, what must they do within 14 days?
Notify the beneficiaries and provide them with an election notice.
If the qualifying event for COBRA is death of the employee, who are the qualified beneficiaries who can elect continuation coverage?
Spouse and dependent child.
If the qualifying event for COBRA is divorce or legal separation, who are the qualified beneficiaries who can elect continuation coverage?
Spouse and dependent child.
If the qualifying event for COBRA is the employee enrolls in Medicare, who are the qualified beneficiaries who can elect continuation coverage?
Spouse and dependent child.
What does the FMLA allow eligible EMPLOYEES to do?
Take up to 12 work weeks of unpaid leave during any 12-month period to attend to the serious health condition of the employee, parent, spouse or child, or for pregnancy or care of a newborn child, or for adoption or foster care of a child.
What is the "election period"?
The 60 day period after the beneficiary receives notice of the qualifying event from the plan or the day active coverage ceases, whichever is later.
What is the "election date" for COBRA?
The day you put it in first class mail.
If the qualifying event for COBRA is the loss of "dependent child" status under the plan, who is/are the qualified beneficiary/ies who can elect continuation coverage?
The dependent child.
If you or your dependents are losing eligibility for group health coverage, including eligibility for continuation coverage, what special right might you have under HIPPA?
The right to special enroll, i.e. enroll w/o waiting until the next open season for enrollment, in other group health coverage. You had to have been covered by insurance and lost it to be able to enroll. You have 30 days to enroll.
If you lose COBRA coverage b/c you failed to pay the initial premium w/in 45 days, what is the way to reinstate it?
There is no way to reinstate it. You lose it.
What does TAA stand for?
Trade adjustment assistance.
Does the FMLA apply to both private and public sector employers?
Yes
If you choose COBRA and not special enrollment, must you exhaust COBRA continuation coverage before you are eligible for special enrollment?
Yes
Is continuation coverage the same as it was when you had active coverage with the same benefits, choices and services?
Yes
Can you get COBRA if you have had FMLA?
Yes, you can get COBRA continuation if you have taken leave under the FMLA, but there has to be a qualifying event, such as quitting your job after your FMLA ends
If you pay your COBRA premium late, but during the grace period, what happens to your coverage?
You are reinstated retroactive to the beginning of the time period at issue.
If you do not pay your initial COBRA premium w/in 45 days of election date, what happens?
You lose coverage
If you do not make up the shortage on a COBRA premium w/in 30 days of notice, what happens?
You lose coverage.
If you do not pay your COBRA premium timely, what happens?
You lose coverage.
Under what conditions does HIPPA give individuals who are losing group health coverage the right to buy individual health insurance coverage that does not impose a pre-existing condition exclusion period?
You must have 18 months of creditable coverage and no break in coverage for 63 days. COBRA coverage is creditable coverage.