Is this Guaranteed Issue?--confused

TN_agent

Guru
100+ Post Club
630
I am a bit confused with a conversation I just had with an underwriter. State of TN.

I have a 66-year old guy with A & B who is still working who left his job to take a new one recently. He lost his employer-based coverage from his previous employer 1/31/16 when he left active employment. He doesn't want to pay for COBRA because it is like 1200 a month for he and his wife.

I submitted a GI application for an F for him. I attached the certificate of continuous coverage from his previous insurance company. He doesn't have the COBRA package yet, was a big hassle to get the COCC from his former employer which is why I didn't submit app until end of February. I get a call from an underwriter asking why he is no longer covered and saying that they need a letter from his employer with the reason that coverage terminated. I state, ok, he left employment and took a new job, that is why the coverage terminated. I ask if the COBRA package would suffice when he gets that, he isn't sure of the time frame when it will come.

She puts me on hold and comes back and says it is not GI because he left his coverage voluntarily. I am confused. He didn't leave the coverage voluntarily, he left the job voluntarily. He would have loved to stay on this very good plan with awesome drug coverage instead of the Part D with donut hole, but unfortunately they won't let him since he no longer works there.

I thought this "voluntary" part only applies to someone voluntarily leaving retiree coverage (that they are otherwise still eligible to continue) OR voluntarily leaving an employer's coverage even though they are still an active employee and otherwise eligible to continue it. I did not think the "voluntary" bit ever applied to when employment terminates, regardless of the reason for termination.

The underwriter stated to me "if the person had retired, it would have been GI, but it isn't GI because they left to take another job". So, if someone works after 65 and leaves a job to take another job, this is not a GI situation, but if they "retire" then it is?

That doesn't make any sense to me. What is the difference between retiring and changing jobs? I think the underwriter may be wrong about this, but wondering where I go from here.

This guy could be put with UHC if it comes down to it for more money. But of course, I would look like an *** who didn't know what they were talking about.

I am getting used to that, though. :D:D:D:D:D
 
You are correct in your thinking TN the underwriter doesn't know what they are talking about. Leave a job with coverage your coverage terminates through no fault of your own. Doesn't matter if cobra is offered unless he accepted it.
 
There might be something more definitive, but I found this on loss of group coverage that is SECONDARY to Medicare.

https://www.medicare.gov/supplement...eed-issue-rights-scenarios.html#collapse-4691

You have Original Medicare and an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays and that plan is ending.
You have the right to buy Medigap Plan A, B, C, F, K, or L that’s sold by any insurance company in your state.

If you have COBRA coverage, you can either buy a Medigap policy right away or wait until the COBRA coverage ends.

You can/must apply for a Medigap policy no later than 63 calendar days after the latest of these 3 dates:

Date the coverage ends
Date on the notice you get telling you that coverage is ending (if you get one)
Date on a claim denial, if this is the only way you know that your coverage ended
 
I interpreted that you have a right "if you have group plan (of any kind or size including retiree or COBRA)" and that coverage ends. OR a union plan that pays after Medicare. I didn't think on the group plan it mattered who was primary, only on the union plan. Some union plans pays secondary regardless of actual employer size because it is considered a multi-employer plan. This is more of an issue regarding opting into part B or not I think.

The reason being, it then goes on to say that you can buy a medigap policy right away or can wait until COBRA exhausts. By definition, only single employers larger than 20 are obligated to provide COBRA benefits, and those group benefits would pay PRIMARY, not secondary to Medicare while in active employment. Yet they state you can get one, so I didn't think that who is paying primary matters except in that stated case of union benefits.
 
You could be right (union plan primary) but it could be interpreted either way (group or union that is primary).

But it also addresses loss of group coverage, not loss of employment. If you lose your job, for whatever reason, loss of group coverage is involuntary.
 
I interpreted that you have a right "if you have group plan (of any kind or size including retiree or COBRA)" and that coverage ends. OR a union plan that pays after Medicare. I didn't think on the group plan it mattered who was primary, only on the union plan. Some union plans pays secondary regardless of actual employer size because it is considered a multi-employer plan. This is more of an issue regarding opting into part B or not I think.

The reason being, it then goes on to say that you can buy a medigap policy right away or can wait until COBRA exhausts. By definition, only single employers larger than 20 are obligated to provide COBRA benefits, and those group benefits would pay PRIMARY, not secondary to Medicare while in active employment. Yet they state you can get one, so I didn't think that who is paying primary matters except in that stated case of union benefits.

Actually it start with Have Original Medicare "AND" an employer group health plan (including retiree or COBRA coverage) or union coverage that pays after Medicare pays and that plan is ending.

This is speaking solely about situations where medicare is primary and does not make mention to situations where group is primary

I Have not had this come up in a long while and can remember ever having issue when someone retired since I was new. Most of my buis is not GI though even in those situations unless necessary.

----------

Also in most cases where Medicare in not part of the group the person would not have part B until retiring so those would generally be OE
 
If they lose group through no choice of their own they are always GI.

In some states if they chose to go off group they are also GI.

If they never had part B and enroll in it due to going off group they are initial enrollment and can take any plan (not limited to GI plans) with no underwriting. You get full commission on those cases.

If they lose group, never had part B but go on Cobra instead of taking Part B, they screwed up. Once they exhaust their Cobra they will have to wait until The next January 1st to sign up for part B which won't take effect until July 1st and will pay a late penalty for the rest of their life.
 
This guy aged into A and opted into B a year ago when he turned 65. He didn't need the B since his employer was more than 20 people, but he wasn't my client then. He lost his OE rights when he did that.

So, the consensus is that this should be a guaranteed issue for an F, right? Involuntary loss of group coverage because of employment termination, leaving the job voluntarily has nothing to do with it.

He has a few health issues but UHC F would still take him if it came to that, but premium would be a bit more than this carrier. If we can get it through GI with an approved letter, it will start tomorrow, not 4/1, I think he would prefer that and the lower premium. And I wouldn't look like a complete buffoon...
 
This guy aged into A and opted into B a year ago when he turned 65. He didn't need the B since his employer was more than 20 people, but he wasn't my client then. He lost his OE rights when he did that.

So, the consensus is that this should be a guaranteed issue for an F, right? Involuntary loss of group coverage because of employment termination, leaving the job voluntarily has nothing to do with it.

He has a few health issues but UHC F would still take him if it came to that, but premium would be a bit more than this carrier. If we can get it through GI with an approved letter, it will start tomorrow, not 4/1, I think he would prefer that and the lower premium. And I wouldn't look like a complete buffoon...

Looks correct to me.
 
Back
Top