In late May, the Centers for Medicare and Medicaid Services (CMS) set up a special Web site where it posted a 13-page application for assistance-eligible individuals (AEIs) covered by public-sector government plans and state mini-COBRA laws to use to appeal the denial of the COBRA premium subsidy under the American Recovery and Reinvestment Act (ARRA).
Although the CMS appeals information can be accessed at http://www.cms.hhs.gov/COBRAContinuationofCov, the key Web site for subsidy denial information is http://www.continuationcoverage.net. The latter site is managed by MAXIMUS Federal Services, Inc. — “a government contractor with experience in performing impartial reviews of benefit claim disputes.” CMS contracted with MAXIMUS to provide administrative case management services and answer the public's questions about premium assistance and COBRA coverage.
Background
ARRA includes a 65-percent subsidy for COBRA premiums paid by AEIs who lose group health plan coverage due to a covered employee’s involuntary termination from employment at any time from Sept. 1, 2008, through Dec. 31, 2009. The law anticipates that there could be disagreements about someone’s AEI status; accordingly, it requires the U.S. Department of Health and Human Services (HHS, or the U.S. Department of Labor (DOL) for private-sector COBRA coverage) to provide for an expedited review for individuals who were denied subsidy eligibility status “by reason of such individual’s ineligibility for COBRA continuation coverage” under federal, state and local governments plans, and in plans regulated by comparable state mini-COBRA laws.
HHS and DOL are supposed to decide these appeals and respond within 15 business days after receipt of the application form. Their review is “de novo”; they do not have to defer to an employer’s decision and can make their own determination, to which any reviewing court must defer.
In an information collection request published in the May 4, 2009, Federal Register, CMS, which is an HHS agency, estimated that 12,000 individuals will appeal under its process.
About the CMS Process
At the Web site
http://www.continuationcoverage.net, CMS notes that individuals with questions can contact a help desk via e-mail at
continuationcoverage@maximus.com or call (866) 400-6689 between 8 a.m. until 8 p.m. EST. They can also download a copy of the application form, “Request for Review If You Have Been Denied Premium Assistance.” There is no online application like DOL has for private-sector employers. Applicants must either mail or fax the CMS application to MAXIMUS.
Otherwise, the CMS form is very similar to DOL’s form (available at
http://www.dol.gov/ebsa/pdf/COBRAapplication052109.pdf?submit=Print+the+...). Both forms ask the applicant the same 10 questions to further determine subsidy eligibility, but CMS does expound on a few questions. Two key differences in the CMS form include: (1) an 11th question that asks whether the applicant exercised any waivers of his or her right to the premium assistance; and (2) a request in the “other information” section to provide more details, such as who told the applicant about the denial; why did the applicant feel he or she was denied; and who informed the applicant about the job loss, what that person said and were other people around at the time.
