Eligibility Guarantee Under COBRA
Provider Type
- Participating Physician Groups (PPG)
- Hospitals
The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) generally allows those who lose eligibility under a group health plan to continue that coverage for a certain period of time at the group rate. Subscribers, and their covered dependents who qualify, are called qualified beneficiaries. Generally, qualified beneficiaries may take up to 60 days from their last day of regular coverage to elect COBRA continuation coverage.
Eligibility guarantee under COBRA does not apply to individual family plans (IFP).
In many cases, COBRA creates problems and delays as the employer sponsor and former plan member carry out various steps before COBRA continuation coverage is effective.
Knowing this, Health Net provides eligibility guarantee protection when the former member certifies that a request for COBRA continuation coverage has been submitted to the employer sponsor of the prior plan. This guarantee is not provided for those who contend that they have not yet requested COBRA continuation coverage, regardless of the time remaining for the former member to elect coverage.
COBRA Eligibility Determination - Not applicable to IFP
Members may be covered by COBRA continuation coverage for up to 18, 29 or 36 months, depending on the event that qualified them for coverage. COBRA continuation can also end at any time.
A member whose name does not appear on the participating physician group's (PPG's) or hospital's current Health Net Eligibility Report or appears with a cancellation notation (a past date in the Provider Cancel Date column of the report) may have become a private-pay member. If the member claims current eligibility because of COBRA, the PPG or hospital should ask the member if COBRA continuation coverage through the employer sponsor of the subscriber's group health plan has been requested.
If the member answers "yes":
- Ask the member to fill out an Eligibility Certification form.
- Provide services with reliance on the eligibility guarantee for the 60-day period following the last day of regular coverage. The PPG or hospital can determine the last day of coverage from an Activity Analysis report from a previous month.
- Call the Health Net Provider Services Center if 60 days pass after the last day of regular coverage and the member does not appear on the PPG's or hospital's current Eligibility Report as NEW CONTRACT with a past date in the Provider Effective Date column.
If the member answers, "No, but I intend to do it within the time period permitted by law," handle the member as a private-pay member, but state that if the member becomes reinstated through COBRA, the member receives a refund of any fees paid.
Eligibility Reports (only applicable to PPGs)
Eligibility records for members who lose eligibility under a group health plan and then obtain COBRA coverage show the following sequence of changes:
- On member's loss of eligibility, the Eligibility Report states "CANCEL MEMBER" or "CANCEL CONTRACT."
- When the member is granted COBRA continuation coverage, the Eligibility Report states "ADD CONTRACT."
- Members who were previously covered as dependents but become subscribers through COBRA are assigned their own subscriber identification numbers.
- COBRA members are assigned group numbers that differ from their previous group numbers only in that the suffix is a different letter.
Filing a COBRA Eligibility Guarantee Claim
COBRA eligibility guarantee claims are filed in the same manner as non-COBRA claims. All requirements and procedures are the same. Refer to the Eligibility Guarantee topic for more information.
Members Not Entitled to COBRA Continuation
Some employer-sponsored health plans are not subject to COBRA.
Members Requesting COBRA Information
If members, regardless of their relationship with Health Net, have questions about what COBRA requires or permits, refer them to their employer sponsor (current or former).