Sect.125 Plan Late Notice Qualifying Event
jmcaa
224 Posts
I would like to know what other self-funded employers would do in this situation.
We have an ee who got divorced in early November 04, didn't receive his court papers until December 20 (48 days later), completed his Health Insurance Change Form (from Family to Single) on Jan. 11, 2005. I received this form on Jan. 18, 2005.
Since notice is over the 31 DAY LIMIT do you refund any employee paid premium? Also, ex-spouse & child had 3 claims paid during that time and one prescription drug filled. What do you do about that?
And since notice was also past the 60 DAY Limit for Cobra Eligibility, his ex-spouse and child are not eligible for COBRA (if they needed it).
Do you give the employee back the difference between the Family and Single premium all the way back to the date of the final divorce decree?
Do you give the employee the difference minus the claims from ex-spouse and child?
Do you only give employee the difference from the date he signed the change form?
Let me know if anyone knows any rules/regulations regarding this type of problem. I couldn't find any.
I do know that if the employee had gotten married in November and didn't turn in a change form until Jan that he would have to wait until open enrollment, but where is the penalty for not timely notifying the plan of changes in this situation?
Thanks for all your help.
We have an ee who got divorced in early November 04, didn't receive his court papers until December 20 (48 days later), completed his Health Insurance Change Form (from Family to Single) on Jan. 11, 2005. I received this form on Jan. 18, 2005.
Since notice is over the 31 DAY LIMIT do you refund any employee paid premium? Also, ex-spouse & child had 3 claims paid during that time and one prescription drug filled. What do you do about that?
And since notice was also past the 60 DAY Limit for Cobra Eligibility, his ex-spouse and child are not eligible for COBRA (if they needed it).
Do you give the employee back the difference between the Family and Single premium all the way back to the date of the final divorce decree?
Do you give the employee the difference minus the claims from ex-spouse and child?
Do you only give employee the difference from the date he signed the change form?
Let me know if anyone knows any rules/regulations regarding this type of problem. I couldn't find any.
I do know that if the employee had gotten married in November and didn't turn in a change form until Jan that he would have to wait until open enrollment, but where is the penalty for not timely notifying the plan of changes in this situation?
Thanks for all your help.
Comments
I would try to put all this in effect when I got the paperwork in January. In particular, the dependents get the full period to elect Cobra or not, from the date they receive the Cobra notification.
I would not refund premiums since the coverage was in effect and claims were paid.
And, our book states it is not obligated to pay for any claims incurred by an ineligible person (which would be the ex-spouse and child).
Divorce and legal separation are events for which the EMPLOYEE has to notify the employer, or forfeit the option of electing COBRA. The employee has to notify the employer within 60 days of the LATEST of the date of the event, the date the person would lose coverage, or the date on which the person is informed, through the plan document/SPD or the general notice of his or her obligation to provide notice, including the applicable procedures he or she must follow to provide such notice. It does not specify that the employee provide documentation of the divorce within the time limit.
If the employee received the court documents 48 days after the divorce, then he could have been timely, if he thought the documents were necessary to notify the employer of the event. I'm puzzled as to why he waited until later.
After this notification to the employer, the employer has 14 days in this situation to send out the election notice, then the employee has 60 days to elect COBRA.
If your plan reads this way, and if the employee didn't actually notify you within the 60 days, then you do not have to offer COBRA to the employee or to any covered dependent qualified beneficiaries. A plan can be more generous, and have a longer period to notify the employer, but of course it would have to apply to everyone, and an amendment to the plan would have to be made.
If you determine that they cannot have COBRA, then coverage would end as of the natural date, end of Nov. or earlier, and premiums/contributions would have to be reimbursed. As for the claims, I would confirm with counsel whether or not they could be deducted from the premium reimbursement. I would think that they could be. Sorry this is so long, and I hope it helps. Oh, if you deny the COBRA offering, then there is another (new) notice that has to be sent to the employee.
But one of the problems is that the CFO says the Employee should be penalized for not taking responsibility to notify the plan within the correct number of days, so he would like to deny the return of the funds.
I was wondering whether any other company has done this?
Look in your plan document; recovery of overpaid claims should be in both Coordination of Benefits and Subrogation, sometimes in just one section, or in General Provisions. Otherwise, retention of overpaid contribution (back to the term. date) would seem to be inadvisable in my opinion. Basically, if there is no coverage, of course there is no cost.
In your situation, the employee is required to maintain the family coverage (which I assume will continue to cover his child) so he does not get any refund. He can then look to make a change to single coverage upon the NEXT change of circumstances OR open enrollment/change period.
As for the ex-wife, she should reasonably have known that her claims would not continue to be paid past the divorce date, and your TPA should initiate the process to request a refund for payment of claims made in error. I would make a note in the file as to why Cobra was not offered in this situation, just for future reference.