by Ljm53 » Fri Jan 25, 2013 04:20 am
Here is our situation. I have been covered by my husbands employers health plan for years. My husband turned 65 in April so auto enrolled in Medicare Part A but did not enroll in Part B since he was still working and covered by his employers plan. My husband retired Dec 31, 2012.
Previous to his retirement, we were told by his HR admin that I would be eligible for a special Cobra extension based on the following Special Extension Rule for Spouses and Dependent Children: "When a covered employee experiences a qualifying event (retirement in his case) within the 18 month period following the employee's entitlement to Medicare (April 2012), the employee's spouse and dependent children become eligible for Cobra coverage a maximum of 36 months. This period is measured from the date of the employee's Medicare entitlement (April 2012), not from the date of the employee's qualifying event (Dec 31, 2012)
SO, we were led to believe that I would be able to Cobra for a total of 27 months which would end March 30 2015. (April to December = 9 months, 36 - 9 = 27 months coverage for spouse and dependent children) I won't be eligible for Medicare until 2018. We have no dependent children.
Now that my husband has retired, we just received the Cobra packet for enrolling. The Cobra CSR states I am eligible only for the standard 18 months coverage. My husband is opting to Cobra for 6 months and then initiate enrollment in Medicare Part B before the end of his SEP 8 month window. At that point only I will continue to Cobra.
I am not independently insurable due to pre-existing conditions. I am not convinced that the Obama care state exchanges will be up and running by June 2014 which is when they say my Cobra ends. I would rather stay on Cobra as long as possible if I am eligible for the extension coverage.
Can anyone confirm whether I should be eligible for the special Cobra extension based on our specific situation? Will Cobra even continue to be available after 2014 for anybody? Will the exchanges provide adequate coverage for persons considered high risk? Thanks for any insight you can offer!
Previous to his retirement, we were told by his HR admin that I would be eligible for a special Cobra extension based on the following Special Extension Rule for Spouses and Dependent Children: "When a covered employee experiences a qualifying event (retirement in his case) within the 18 month period following the employee's entitlement to Medicare (April 2012), the employee's spouse and dependent children become eligible for Cobra coverage a maximum of 36 months. This period is measured from the date of the employee's Medicare entitlement (April 2012), not from the date of the employee's qualifying event (Dec 31, 2012)
SO, we were led to believe that I would be able to Cobra for a total of 27 months which would end March 30 2015. (April to December = 9 months, 36 - 9 = 27 months coverage for spouse and dependent children) I won't be eligible for Medicare until 2018. We have no dependent children.
Now that my husband has retired, we just received the Cobra packet for enrolling. The Cobra CSR states I am eligible only for the standard 18 months coverage. My husband is opting to Cobra for 6 months and then initiate enrollment in Medicare Part B before the end of his SEP 8 month window. At that point only I will continue to Cobra.
I am not independently insurable due to pre-existing conditions. I am not convinced that the Obama care state exchanges will be up and running by June 2014 which is when they say my Cobra ends. I would rather stay on Cobra as long as possible if I am eligible for the extension coverage.
Can anyone confirm whether I should be eligible for the special Cobra extension based on our specific situation? Will Cobra even continue to be available after 2014 for anybody? Will the exchanges provide adequate coverage for persons considered high risk? Thanks for any insight you can offer!
Posted: Fri Jan 25, 2013 01:15 pm Post Subject:
You husband should enroll in Medicare Part B as soon as possible. There is no advantage to waiting 6 months, and every possibility that he makes some kind of mistake and ends up with a LIFETIME premium penalty.
While your current COBRA extension may be 18 months based on the "termination of employment" qualifying event, but you will have a "secondary qualifying event" that will extend the total continuation period to 36 months from the date of the first qualifying event when he enrolls in Medicare Part B.
If you are in an area with multiple Medicare Advantage HMO/PPO plans, I am sure your husband will discover there are better benefits available at lower cost than his 100% premium under COBRA continuation.
Posted: Sat Jan 26, 2013 01:45 am Post Subject:
Thanks for the response Max! The reason my husband has opted to Cobra for a few months is he is in the process of obtaining specific DME equipment that is not covered by Medicare Part B. His current coverage through his employer plan is a BCBS EPO with 90/10 coverage and no deductibles. Since the service date for the DME is when it is physically in his possession and he is still waiting on the medical necessity documentation, he is continuing his coverage under Cobra until all claims have cleared and been reimbursed. This will be a big out of pocket savings with the 90/10 coverage of the current plan and will make up for his short duration Cobra premiums.
He is well aware of the 8 month SEP window for signing up for Part B and will be initiating that process in June with his window running out in August. Hopefully, 2 months lead in time will be enough to process his Part B enrollment without penalty. If your experience tells you we need more time than that please let us know. My husband is planning to sign up for Medicare Part B, Part D, and Part F Supplemental versus the Medicare Advantage plans.
We are led to believe that the Advantage plans have more out of pocket copays where Medicare F Supplemental will pick up everything not covered by Parts A and B. The Medicare prescription Plan D currently has all my husbands prescriptions listed in their formulary. My husband also has longstanding chronic health issues and will need access to ongoing physical therapy and DME services which can become more costly with the Medicare Advantage plans....or so we have been led to believe. Please feel free to contradict or illuminate further based on your experience. We really don't have a clue other than the "Medicare and You" booklet, internet searches and talking with friends already on Medicare.
Regarding my Cobra extension eligibility, I appreciate your confirmation of what I have surmised from reading Cobra rules on the DOL and CMS websites. I will be discussing this issue further with the employer's Cobra and make sure they interpret my eligibility in the same way. Presuming Obama care exchanges will actually be available and functional by 2014, I prefer retaining my ability to opt into the employers plan as long as that remains the higher quality healthcare plan. I am in a "wait and see" mode regarding the exchange system and believe nothing is a given at this point other than it is most likely to be a very bumpy ride for all Healthcare in general. While I am personally very glad to see that patients with Pre-Existing Conditions cannot be denied coverage, I share concerns that Healthcare in America is going to suffer in availability and quality while becoming an even greater financial burden.
Thanks again Max for your input and I am still open to further education as needed of options I am either not fully understanding or aware of.
Posted: Sun Jan 27, 2013 04:16 am Post Subject:
The durable medical equipment explanation makes sense. Thanks for clarifying that.
Hopefully, 2 months lead in time will be enough to process his Part B enrollment without penalty.
This should be sufficient. To do this right, however, you should use the Social Security online appointment scheduling feature about 3 months prior to expiration (it can take a month to get an appointment date). The effective date of coverage (July 1 or August 1 or sooner) can be preestablished to coincide with the termination of COBRA premiums/coverage.Medicare F Supplemental will pick up everything not covered by Parts A and B.
Don't believe this! If a service is NOT COVERED AT ALL by Medicare, it also will not be covered by the Medicare Supplement insurance.This is a BIG DIFFERENCE compared to Medicare Advantage plans that generally offer a much wider array of benefits than Medicare provides (like dental coverage and orthopaedic care for arthritis) -- but these benefits vary according to each plan, and you need to review the coverages of several to determine which would be in your husband's best interest. As for copays, depending on where you live, competition among the various Medicare Advantage players can completely eliminate copays in some plans (that is true of some plans here in Southern California).
Take some time to check out Medicare Advantage plans in your area. Begin at http://medicare.gov/ where you will be getting the government's information straight from the source. Then you can approach a local agent who can assist you with obtaining brochures and other information and enrollment.
My husband also has longstanding chronic health issues and will need access to ongoing physical therapy and DME services which can become more costly with the Medicare Advantage plans....or so we have been led to believe.
This has no been my "experience." I enrolled my mother in her local Medicare Advantage PPO beginning in 2007, and she has had phenomenal care when necessary at very nominal out of pocket cost (in reality the Part D program costs her the most -- even though she gets the "extra help" -- because prior to the inception of Part D, her medications (like those of many other seniors) were provided at no charge by arrangement between the State of Washington and the various pharmaceutical companies.
She had a $150,000+ five day hospitalization a couple of years ago, and her total out of pocket was $875. I pay her monthly premiums which are the lowest this year out of the past seven years, as more seniors have enrolled.
You should find the same or similar experience in your area.
I share concerns that Healthcare in America is going to suffer in availability and quality while becoming an even greater financial burden.
Welcome to the "club." There is little hope of Obamacare fulfilling the promises upon which it was "sold" to the American people through the series of 2008 "Town Hall Meetings" that were well-orchestrated and, in some cases, well-scripted for the benefit of the news media covering the events.
Posted: Mon Jan 28, 2013 01:57 pm Post Subject:
Thanks Max! Very helpful information. Really appreciate the tip about the online scheduling feature for making an appointment. Was not aware of that.
My husband is now starting to gather information on our Local Medicare Advantage PPO plans based on your comments. We are in St. Louis Mo. so the big names here are AARP-United Healthcare and Anthem BCBS. There are any number of other Advantage plans with companies that have less market share in our area. While cost is certainly important, we are willing to pay a little more if it provides the most complete coverage package.
My husband's primary needs in a plan is the ability to choose his physicians, medical facilities and service vendors, no rigid restrictions on DME or therapy services, and a full prescription formulary including both brand name and generics. So he is looking for a premium package that is well managed and worth the extra cost.
We also are seeing new PFFS plans in our area but I have little knowledge of how they work and suspect they may not be the best choice for someone with pre-existing chronic illness.
I am aware of the prescription formulary comparison websites for Medicare Part D vs the various Advantage plans and that will be helpful in making sure all his prescriptions are covered. The medicare.gov site is an excellent resource and we will continue to research it, but if we wanted to know the specifics of any restrictions on DME ie. wheelchairs, mobility devices, in-home patient lift devices, CPAP equip etc. what is our best method of finding this out? Directly calling the plan managers and asking for specifics? Will a local agent have access to more information than is available in a brochure?
We have discovered that while Medicare may pay for items from these categories, they severely limit the list of "approved" DME items when it comes to brands, features and functionality. Do you believe that an Advantage Plan will operate under a broader approach to DME and allow the patient specific equipment if deemed medically necessary?
These are the types of issues that would definitely make a difference in my husband's choice of whether to go with a Medicare Supplemental or an Advantage Plan. I am a little confused though by what I am reading about a limited ability to switch between Medicare and Advantage plans. I'm not sure if it is better to start out on an Advantage plan first and later switch to Medicare Supplemental if necessary or start out with Medicare first and switch to Advantage? I read a switch from Advantage to Medicare must be made within 12 months in order to have full access to the Medicare plans? And something about not being allowed to switch between Medicare and Advantage at all after a certain point? So it sounds like a person can get "locked" in to either the Medicare Original side or the Advantage side? You can change your choices at annual open enrollment each year but must stay on one side or the other? Is that true or am I totally off base?
Thanks again Max for your help and insight! Hope you don't mind all the questions. :)
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