Why is COBRA only paying 20 percent of claim?

Toni,

I need your Medicare guidance because in December, I was rushed to the ER because of kidney failure caused from stage 4 of prostate cancer which has spread to my pelvic bones.

Because I was working full-time, I took a leave of absence with short-term disability in January for 60 days while receiving my cancer treatment which ended on Feb. 28.

I was informed while in the hospital for cancer treatment that I had qualified for long term disability and would no longer be part of the company's health plan since I was not a full-time employee. COBRA would begin immediately.

I enrolled and paid for COBRA to continue with medical care where I am having cancer treatment. It took six weeks to get the paperwork to Social Security for Medicare Part B to begin May 1 which it has since I was not working full-time. Now my Cobra nightmare begins!

COBRA is only paying the 20 percent of medical bills and I was billed the 80 percent because I was not enrolled in Medicare Part B which has totaled over $40K. Please help me solve this COBRA financial nightmare ... Thanks, Robert, Tomball, TX

Hello Robert:

Those reading this article need to realize the seriousness of Medicare and insurance rules.

The Medicare & You handbook discusses topics such as "Special Enrollment Period" and "Should I Get Part B?" It states that "COBRA" is not considered "coverage" based on current employer benefits.

You have eight months to sign up for Medicare Part B without a penalty if you are not "working full-time or have lost your company benefits, whichever comes first." The eight-month period will run whether you choose COBRA or not. COBRA has an 18-month benefit period.

If you choose COBRA, do not wait until your COBRA ends in 18 months to enroll in Part B. The COBRA benefit period is longer than the eight-month Medicare Special Enrollment Period, and you may receive the famous "Medicare Part B penalty" which goes all the way back to when you enrolled in Medicare Part A.

Robert, you did everything correctly to enroll in Medicare Part B by contacting Social Security and faxing the CMS-L564 form "Request for Employment Information," signed by your company's HR department, and CMS-40B form "Application for Part B." Fortunately, at least, you were still within the correct time limits for your Medicare Part B to begin May 1.

You are in a Medicare "glitch" and the COBRA health plan is using "Coordination of Benefits" as their ruling. Chapter 1 of Toni's Medicare Survival Guide Advanced edition explains various ways of enrolling in Medicare in detail. Visit www.tonisays.com for Medicare information.

Group health insurance plans are a state-regulated, not a Medicare regulated plan. Since you are past 65 and already enrolled in Medicare Part A, the health plan is passing the 80 percent of the doctor/medical bills on Part B to Medicare. You were not enrolled in Medicare Part B from March 1 to April 30 for Medicare to pick up the difference.

A bit of good news is that COBRA plans are a creditable prescription drug coverage plan, and you are eligible for a Special Enrollment Period of 63 days to enroll in Medicare Part D plan without receiving a Part D penalty. Please enroll in your Part D prescription drug plan ASAP.

Remember, with Medicare what you don't know WILL hurt you! Need Medicare help, then call the Toni Says Medicare hotline at 832-519-8664 or email [email protected] for Medicare help.

Toni's book "Medicare Survival Guide Advanced" edition is offering a $10 discount available to the Toni Says® readers and their friends at www.tonisays.com and www.seniorresource.com. Visit www.seniorresource.com/medicare-moments/ to listen to Toni's Medicare Moments podcasts.