Health Insurance; COBRA; OBRA; HIPAA; Medicare; Definitions, Relationships

Health Insurance; COBRA; OBRA; HIPAA; Medicare. If asked, could you state that you knew that all 5 of these topics had the same thing in common: medical insurance coverage for you and, perhaps, your family? Would you know the qualifications for each? Well, in this article, we will discuss them. For a timeline that depicts, graphically, the time relationship between them, please see the timeline in
HEALTH INSURANCE Coverage from Work
If we are lucky, we, and/or our spouse, work for a company that provides, as a benefit, health insurance coverage for us and our family. If so, we are very lucky. Even if that is true, there are some key things that you might want to look at to see if you have ENOUGH coverage.
1) From your Human Resources Department (or wherever else you would go to get information about your health insurance) get what is called a “Summary Plan Description” (SPD). This document should be kept where you can always find it, as it contains all the information you will need about what your insurance covers and what it doesn’t.
2) Look up “Coverage” and “non-coverage” in your SPD.
These will tell you what your plan covers and doesn’t cover. You need to see if, perhaps, you or one of the covered members of your family has a condition or circumstance that might not be covered, where you need additional coverage. For example, let’s say that your family has a history of cancer; perhaps your plan restricts the number of hospitalization days for care; or, restricts the days per condition. In this case, (like my children) you might want to get additional “cancer insurance” (I think that AFLAC might provide this type of coverage).
It would be a good idea to contact a Health Insurance benefit Broker and ask him/her to read your SPD and see if you have any gaps in coverage. They then can help you supplement coverage BEFORE YOU NEED IT!
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Whenever you call or email a Health Insurance Broker, it is very important to prepare ahead of time. WHAT, specifically are you looking for; how much can you afford to pay every month; what circumstances do you want to make sure that your family is covered for. In this way, you can make sure to focus on your critical needs.
COBRA is an acronym ( how can I spell acronym correctly, yet not be sure that I spelled catestrophic correctly?) that stands for: Consolidated Omnibus Budget Reconciliation Act. Basically, it is a federal law that allows you to pay for your Company-paid health insurance, as an active member, if you no longer work for that company for, generally 18 additional months.
1) COBRA is “triggered” (that is, you, or a covered member of your family, become eligible for COBRA) by events such as the following: resignation from the company; termination (FOR ANY REASON) from the company; divorce of a spouse; a covered chile’s birthday makes them ineligible for coverage. These are the main “triggering” events for COBRA.
2) Now, when eligible for COBRA, you will be asked to pay for 100% to 105% of the company’s employee/employee and family coverage amount. You should get a letter from your company explaining what that amount will be. BEFORE YOU DECIDE TO TAKE COBRA, there are some important things for you to consider.
What will be your cost, and what will be the coverage for that cost? Sometimes the cost is too much for the coverage. In these cases, you might want to select HIPAA coverage, instead (see HIPAA below).
Or, you might just want to get catestrophic coverage as was mentioned earlier, and wait for full coverage under your next job.
Part of this decision should be whether or not you or a member of your family has what is called a “pre-exisitng coverage” condition.
Here again, before automatically taking COBRA, it would be wise to contact a Benefits Insurance Broker and give him/her all of your options, and get their input. I have worked extensively with a Benefits Insurance Broker, and he is absolutely fantastic!
What, you ask, is OBRA? I’ve never heard of it, you say, and no one I know has heard of it either! Well, that’s because, 99% of Human Resource or Benefit folks that I know have never heard of it! OBRA is a federal law that was passed that extends COBRA for an additional 11 months FOR DISABILITY PURPOSES ONLY!! Why, you ask, is this important? Thanks for asking, let’s see if I can explain.
If you are as nieve (did I spell this wrong too? sorry!) as I was when I first started looking to bridge my health insurance from working to Medicare, I assumed that when I got through all of the hoops to qualify for SSDI (Social Security Disabililty Insurance) I’d IMMEDIATELY be eligible for Medicare, RIGHT??? WRONG!!!!
When you FINALLY qualify for SSDI, you have to wait for 5 months before you get your first check. AND, the rules state that, you are eligible for Medicare 2 years (24 months) FROM THE DATE OF YOUR FIRST SSDI PAYMENT. Well, if you add 24 + 5 you get, 29 months between qualifying for SSDI, and Medicare coverage.
OK, I said earlier that COBRA is for 18 months of coverage. Well guess what 18 months of COBRA + 11 months of OBRA equal – 29 months!
BUT, there are two catches to OBRA; first of all, you have a small window of 30 – 60 days to apply ( this window opens the date of your SSDI approval); and, it can cost up to 150% of your plan coverage amount. BUT, if you have a “previously existing condition” this might be the best way for you to proceed.
Again, it is important to contact a Health Insurance Broker to help you with the risk/cost ratio of all of these situations.
It is also improtant to know all of these deadlines as you plan to ensure that you and your family have important health insurance coverage.
HIPAA is a federal law that is called, briefly, the “portability” law for health insurance. What that means is that when you leave a group (read company-paid plan), the carrier that provided that plan, must offer to you, another plan, different from COBRA, when you leave the group coverage. Generally this will be what is called a “bare bones” plan. Again, the best thing for you to do is to call/email a Health Insurance/Benefits Broker with all of your information: SPD, COBRA info, HIPAA info, needs, cost limits, and let him/her help you find the optimum plan coverage for you.
OK, now, finally, we’ve reached Medicare! BUT (you really didn’t think it would be that easy, did you?) if you have qualified for Medicare because of disability, there are RESTRICTIONS (of COURSE there are!).
First of all, if you are qualifying for Medicare because of disability, you are probably under the age of 65 – normal retirement age.
Medicare coverage does NOT cover prescription drugs, which, those of us with disabilities probably need, and which cost lots.
But, Congress prescribed that states (all but 11) offer what is called “Medicare supplement” plans, some of which do offer prescription coverages.
BUT, these plans ARE NOT REQUIRED TO, and do not, offer these medicare supplement plans that offer prescription coverages to folks who qualify under age 65! So, if you are qualifying because of disability, your medical insurance plan doesn’t cover one of your primary cost expenditures!
Here again is where you need to contact a health insurance/benefit broker. Again, he/she can work with you, and your specific circumstances, to get you the coverage you need.
Hope that this information was helpful to you. If you have any questions, please feel to ask them by commenting on this blog, and I’ll be happy to get you an answer.