COBRA, "Consolidated Omnibus Budget
Reconciliation Act" is a federal act that ensures health insurance
coverage for a limited period to people, who lose their previous coverage
because of one of the stated reasons. The reasons could be like Termination,
Divorce etc. Even in case of Death of an employee, the covered dependents get
COBRA coverage.
In short, if anyone was covered in any health
plan provided by a firm, upon end of the coverage, the beneficiary gets a
chance to stay covered for another few months. This is the simple logic of
COBRA. This is in place to make sure no one gets de-enrolled from health
coverage all of sudden. However there are clauses. The Beneficiary can get the
COBRA Coverage only for 18 months. There are clauses with which the duration
might get increased. The Beneficiary once enrolled has to pay 102% of the
premium to the firm. So the Person pays 100% of the Premium, and again 2% of
the premium to the firm, as a service charge; as the firm provides him
the privilege of staying enrolled. Here are some details:
- Upon
Termination of coverage, all covered dependent of a Participant, are
eligible either to continue with their own COBRA Coverage/ to be covered
under the Original Participant.
- Unless a
firm has less than 20 employees as of the previous year, it must comply
with COBRA.
- The system
checks for non COBRA Coverage as of day before COBRA coverage start date
to allow / decline COBRA Coverage.
- COBRA
rates are always 102% of the Premium, unless the Employer wants to match.
- COBRA
usually provides only the Health Coverage plans: Medical, Dental, Vision.
Sometimes with Prescription drugs, Health care spending
accounts, and Dependent Healthcare Spending Accounts.
- All the
rates for COBRA comp objects are pulled from Participant directly; hence
the activity type is always "Participant Individual
Contribution".
- If a
participant fails to pay the COBRA Rate for a defined period, the
Participant looses the Coverage. However a few firms allow a grace period
to the employees, within which the Participant must pay.
- Once found
eligible to COBRA, the person gets a 60 days enrolment window to elect his
COBRA Coverage. If nothing is selected in a plan type, it’s considered a
non enrolment, so no default / waive default applies.
- The
employer is also responsible to intimate the Participants about their
COBRA Coverage and enrolment Opportunities.
Now, let's discuss some functional parameters.
- Benefit
Structure: We should have a separate COBRA Program to handle the COBRA
Participants separately. Although it is not mandatory to have a different
program itself; it is always better to have it separated from the other
Programs. It helps in Rates and Eligibility determination.
- Life
Events: We must have COBRA Life Events to initiate, maintain and terminate
COBRA enrolments.
- Enrolments:
The COBRA program enrolment requirements are bit different than the other
programs, and we need to add them in place.
- Eligibility
and Rates: The COBRA eligibility Profiles and Rates are very different
than the regular ones.
- Communications
and Extracts: We must set up the COBRA Communication types, the Extracts
and the concurrent schedule to process the same.
So, we will have to take care of these five
points in order to configure COBRA Program. We will discuss the points one by
one and discuss how they help in setting up the Regulations.
Benefit Structure
- There
should be a separate COBRA Program.
- Put the
Program Type as "COBRA" or "COBRA with Credits"
- The
"Determine Enrolments Period Level" should be set to the level
in which the COBRA Regulations are applied. It is advised to use PTIP.
- The COBRA
Administrator details must be entered, so that it appears correctly on
SSHR and Communications. It can be done in Programs and Plans. For
Programs, in Organization tab, enter our enterprise name, Name of the
COBRA Administrator Person, and Role type as Administrator, in
Organization, Organization Roles, and Organization Role Types fields
respectively.
- Continue
with the same set of plans as the COBRA PLIPs will be different than that
of the general PLIPs.
- The Plans
should have the COBRA Payment day defined.
- The Plans
should have the COBRA Regulation attached in details window.
Life Events
- The
following Life Events are needed to manage COBRA
- Loss of
Eligibility: Triggered when a Participant does not make any elections in
the COBRA Qualifying event, hence losing the eligibility to the Program.
- Non or
Late Payment: Triggered when a participant fails to make a payment /
makes a late payment.
- Maximum
Enrolment Period Reached: This LE is triggered when the Participant
reaches the end of maximum period, either 18 months or more, based on the
law.
- Voluntary
End of Coverage: Triggered when the Participant voluntarily asks for a
termination in coverage.
- Apart from
these Maintenance life events, we will also need the Qualifying Life
Events like, Termination, Retirement, Divorce, Death of a Participant, and
Dependent Age out etc.
- The
Qualifying Events must have their "COBRA Qualifying Event" flag
checked.
- The Life
Event eligibility must be defined at PTIP level; with Eligible/Ineligible
code as "Either Eligible or Ineligible" and Max enrolment value
as 18 months/ more as per the legislation.
- The Maintenance life
events must have the Life event eligibility defined as well; however
with Eligible/Ineligible code as "Ineligible".
Enrolments
- We need to
set up our COBRA life event enrolment rules in such a manner that the
Participants will not be able to change their Enrolment in the middle of a
plan year.
- No
Defaults are set up for COBRA enrolments. If the Participant does not
choose anything, he gets nothing.
- The
Minimum and Maximum number of enrolment allowed in the COBRA PTIPs can be
made to 0 and 1 respectively; just to make sure we allow a participant to
have "No Enrolments" too.
- The
Coverage start date and end date should be made in sync. Either always
follow first of next month logic, or follow Event date logic, it all
depends on the COBRA Qualifying Life Events.
Eligibility &
Rates
- The
Eligibility Profiles must be based on each Plan types, set up in a manner,
that it allows only two type of persons
- The
Participant is either experiencing a COBRA Qualifying Event / does have a
COBRA Qualifying Beneficiary Record. The first one is for the First time
eligible employees and the second one is for the Participants who are
already in the Program.
- Participants
who were enrolled in the Plan type as of Day before Coverage Start Date;
and are not found eligible as of Coverage Start Date. They should
not have Eligibility to any other coverage too. The Eligibility to Other
Coverage can be recorded in the Person DFF.
- Participants
who are enrolled in Medicare, lose their coverage in Regular / COBRA
benefits; however if a Participant Opts for Medicare once he is in COBRA,
its dependent can continue in COBRA for 36 months.
- Dependents
that were covered in the plan type as of Day before Coverage Start
Date; and are not found eligible neither to be covered, not to
participate as of Coverage Start Date.
- We can
again extend the eligibility in such a manner that, participants get only
those plans in which they were enrolled as of day before Coverage
Start Date, and the waive plan as an option to waive out.
- The same
functionality can be used in Options as well; however we should allow the
Participants to use the less-than- equals to options (Options with same or
lower tiers)
- The
Dependent Eligibility Profiles should be updated accordingly.
- Rates
should always be 102% of the Premium.
- The
activity type should always be the "Participant Individual
Contribution".
- We should
avoid standard Variable Rate Profiles, unless needed.
Communication and
Extracts
- The COBRA
letters are seeded by Oracle, we can then use the standard COBRA letters
or we may write our COBRA letters using an Extract.
- In the
Communication types, for the COBRA Confirmation Letter
- The
Trigger should be set as : Post Enrollment Confirmation Literature
-Form- Enrollment Results Created/Modified/Deleted
- The
usages must have the Program name listed.
- For the
"COBRA Benefits Notification Letter" and "COBRA Benefit
Initial Information"
- The
trigger should be : Eligibility Literature - BENMNGLE- Determines
First Time Eligible
- The two
processes: COBRA Benefit Notification Letter and COBRA Benefit
Initial Information can be used to create COBRA Literature on one person
/ organization / Benefit Group / Locations.
- There is
a provision to update the seeded report with XML Publisher as well.
HIPAA stands for
Health Insurance Portability and Accountability Act. Although there were many
clauses attached to this law; this act was mainly brought in to effect in 1996
to eradicate issues related to the Privacy of one’s health coverage history.
To know in
simple language, a person who is enrolled in an Insurance Plan, is eligible to
get a report of his Insurance history (enrolment start date, end date,
Coverage) whenever he wants. So that he can supply the same to a new carrier
for a new coverage. Sometimes Carriers need a similar kind of report, explaining
someone’s insurance history, for a continuation of Coverage.
Now, there is a
clause. The transfer of data must not be publicized. It must be done through a
secure data transfer from one carrier to the other; so that the data is not
available to anyone else other than whom it was meant to be.
Setting up HIPAA
is very much simple, and straight as designed by Oracle. The changes that we must do to accommodate
HIPPA are:
·
Create or Update our Reporting
Group to include HIPAA in it, as a regulation.(Same as we did for COBRA)
·
Update all our HIPAA Regulated
Plans with HIPAA added as part of regulations.
·
Now, our HIPAA is set up.
The next thing
we want is, setting up the communication, isn’t it? For that, we will have to
go to the Maintain Communication type screen. If we query for it, we will find
two seeded HIPAA letters there, HIPAA Letter and HIPAA Dependent Letter.
In the HIPAA
Dependent Letter: Add the following two triggers: - HIPAA Dependent Loss of
Coverage - HIPAA Dependent Lost Coverage
- On-Line Participant Based
Literature Requests - On-Line Request
And in the HIPAA
Letter: Add the following two triggers: - HIPAA Participant Deenrollment
- HIPAA Participant Deenrolled
- On-Line Participant Based
Literature Requests - On-Line Request
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