Determining COBRA Premiums for Fully Insured and Self-Funded Health Plans

The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) allows qualified beneficiaries who lose health benefits due to a qualifying event to continue group health benefits. While some group health plans may provide COBRA continuation coverage at a reduced rate or at no cost, most qualified beneficiaries must pay the full COBRA premium. The COBRA election notice should include information about COBRA premiums.

For fully insured health plans, the premium is the cost to maintain the plan for similarly situated employees. For self-insured plans, the premium is the cost to maintain the plan for similarly situated employees as determined by an actuary or the past cost from the preceding determination period. The applicable premium calculation for both fully- and self-insured plans includes the cost of providing coverage to both active employees and COBRA qualified beneficiaries. All COBRA premiums must be calculated in good faith compliance with a reasonable interpretation of COBRA requirements.

Generally, COBRA payments are made on an after-tax basis. Qualified beneficiaries have 45 days after the election date to make an initial premium payment. The plan may terminate the qualified beneficiary's COBRA rights if no initial premium payment is made before the end of the 45-day period. In addition, plans must allow monthly premium payments and cannot require payment on a quarterly basis. As established under COBRA, premiums are due on the first day of each month with a minimum 30-day grace period. A plan may terminate COBRA coverage for nonpayment or insufficient payment of premiums after the grace period.

If a qualified beneficiary makes an insignificant underpayment, then the premium payment will still satisfy the payment obligation. An underpayment is deemed insignificant if the shortfall is no greater than the lesser of $50 or 10 percent of the required amount. However, if the plan notifies the qualified beneficiary of the shortfall and grants a reasonable amount of time to correct the underpayment (usually 30 days after the notice is provided), then the qualified beneficiary is required to make the payment; otherwise, COBRA coverage may be canceled.

Fully Insured Health Plans

Generally, the applicable COBRA premium amount for fully insured plans is the insurance premium charged by the insurer. The applicable premium is based on the total cost of coverage, which includes both the employer and employee portions. The premium amount is based on the cost of coverage for similarly situated individuals who have not incurred a qualifying event.

A group health plan may charge at most 102 percent of the premium during the standard COBRA coverage period for similarly situated plan participants (100 percent of the total cost of coverage plus an additional 2 percent for administrative costs). However, the plan may increase the premium for a disabled qualified beneficiary and charge 150 percent of the applicable premium during the 11-month disability extension period (months 19 through 29). In addition, COBRA regulations permit a plan to charge a 150 percent premium to nondisabled qualified beneficiaries as long as the disabled qualified beneficiary is covered under the plan. If the disabled qualified beneficiary is no longer covered under the plan, then the remaining qualified beneficiaries may continue coverage up to 29 months at 102 percent of the cost of the plan.

If an employer maintains more than one plan, then a separate applicable premium is calculated for each plan. Also, the applicable premium for a single plan may vary due to factors such as the coverage level, the benefit package, and the region in which covered employee resides. For instance, single employees may pay a different applicable premium than employees who include their spouse on the plan. Thus, the plan may charge different premiums based on the varying coverage levels.

The most common tier structures include employee-only, employee-plus-spouse, employee-plus-children, and employee-plus-family. According to Internal Revenue Ruling 96-8, a fully insured plan that pays different premiums for individual versus family coverage must use those same premium tiers for COBRA continuation coverage. Thus, COBRA premiums are divided into multi-rate and single-rate tier structures.

_{By Danielle Capilla
Originally Published By United Benefit Advisors}