The week you lose a job is the week you most need the person you have been seeing, and it is the week the coverage that pays for them ends. There are four ways to keep the coverage or the therapist, and each has a clock.
The short answer: usually, yes — and the clocks are what matter. If your employer had 20 or more employees, federal COBRA lets you keep the same plan for "18 months after the date of the qualifying event," at a premium that "shall not exceed 102 percent of the applicable premium," and the election period "is of at least 60 days' duration."¹ ² If the employer had 2 to 19 employees, California's Cal-COBRA does the same job for up to 36 months at "not more than 110 percent of the applicable rate charged for a covered employee," with a 60-day election window and 45 days to pay the first premium; and when federal COBRA on an insured California plan runs out at 18 months, "18 more months of Cal-COBRA is available."³ ⁴ If you would rather change plans, losing coverage opens a Covered California special enrollment period — "60 days before and after the date of the loss of coverage to select a QHP" — and "Medi-Cal enrollment is also year-round."⁵ And if you move to a new plan while in the middle of treatment, the new plan must, at your request, "provide for the completion of covered services" by your out-of-network therapist for the conditions the continuity-of-care statute lists — including a serious chronic condition — if you were "receiving services from that provider" when the new coverage began and the therapist accepts the plan's terms, unless you "voluntarily chose to change health plans" when you could have kept the old one.⁶
Route 1: keep the plan (federal COBRA)
Federal COBRA applies unless "all employers maintaining such plan normally employed fewer than 20 employees on a typical business day during the preceding calendar year."¹ For a job loss or reduction in hours, coverage runs to "the date which is 18 months after the date of the qualifying event," and the premium "shall not exceed 102 percent of the applicable premium for such period" — up to 102 percent of the plan's full cost of your coverage, employer share included.² If Social Security finds you were disabled "at any time during the first 60 days of continuation coverage," the 18 months becomes 29, provided you notify the plan of the determination before the 18 months end, with the premium allowed to rise to 150 percent after month 18.²
The election period "is of at least 60 days' duration," ending "not earlier than 60 days after the later of" the date coverage ended or the date you received the notice.² Coverage "must extend for at least the period beginning on the date of the qualifying event" — it is retroactive to the loss, which is why the first premium bill is large and why the sessions in between are covered — and no premium can be required before "45 days after the day on which the qualified beneficiary made the initial election."²
Route 2: keep the plan (Cal-COBRA)
"Cal-COBRA applies to employers and group health plans that cover from 2 to 19 employees."³ Coverage runs to "the date 36 months after the date the qualified beneficiary's benefits under the contract would otherwise have terminated because of a qualifying event."⁴ You must elect "within the 60-day period following the later of (1) the date that the enrollee's coverage under the group benefit plan terminated or will terminate by reason of a qualifying event, or (2) the date the enrollee was sent notice," and pay the first premium "within 45 days" of giving written notice of the election.⁴ The premium is "not more than 110 percent of the applicable rate charged for a covered employee."⁴
Cal-COBRA also has a second job. When federal COBRA's 18 months ends, "18 more months of Cal-COBRA is available" — a total of 36 — from the same plan, if the plan is an insured California plan; the state says an employee covered by a self-funded plan or an out-of-state plan does not qualify.³ Termination "for gross misconduct does not constitute a qualifying event" under the state statute, and the federal one likewise excludes "termination (other than by reason of such employee's gross misconduct)."⁴ ⁷
"You should get a notice in the mail about your COBRA and Cal-COBRA rights. If you are eligible for Cal-COBRA and did not get a notice, contact your health plan."³ The DMHC Help Center is 1-888-466-2219.³
Route 3: change the plan (Covered California or Medi-Cal)
Losing minimum essential coverage is a triggering event for a special enrollment period: "60 days before and after the date of the loss of coverage to select a QHP."⁵ A loss caused by "failure to pay premiums on a timely basis" does not count, except where an employer's contributions to COBRA coverage or a government COBRA subsidy completely cease; a voluntary termination of coverage does not count either.⁵ Covered California's own page adds: "Medi-Cal enrollment is also year-round."⁵ Medi-Cal and therapy → · Covered California plans and therapy →
The catch: a new plan means a new network. Check whether your therapist is in it before you pick. The directory said in-network. It wasn't. →
Route 4: change the plan and keep the therapist anyway
The continuity-of-care statute reaches new enrollees, not only people whose therapist left a network. "The completion of covered services shall be provided by a nonparticipating provider to a newly covered enrollee who, at the time the enrollee's coverage became effective, was receiving services from that provider for one of the conditions described in subdivision (c)."⁶ Those conditions include an acute condition and "a serious chronic condition," for which completion "shall not exceed 12 months… from the effective date of coverage for a newly covered enrollee."⁶ The plan can require the therapist to accept its contractual terms and rates; if the therapist will not, "the plan is not required to continue the provider's services."⁶ The conditions, and how to ask →
The exclusion matters: "this section does not apply to a newly covered enrollee who is offered an out-of-network option or to a newly covered enrollee who had the option to continue with their previous health plan or provider and instead voluntarily chose to change health plans."⁶ Whether declining COBRA counts as voluntarily choosing to change plans is a question the statute does not answer in terms; ask the new plan in writing, and cite the subdivision.
Which route, in one paragraph
If the therapist is the point and the premium is survivable for a few months, COBRA or Cal-COBRA keeps everything exactly as it was, retroactively, while you sort out the rest. If the premium is not survivable, a Covered California plan with your therapist in network, or Medi-Cal, is the answer — and if neither has your therapist, the continuity-of-care request under Route 4 is the last tool. COBRA and Cal-COBRA give at least 60 days from the later of the loss or the notice; Covered California gives 60 days on either side of the loss; the continuity-of-care request has no 60-day deadline, but ask before the first session with the new plan.
Worked example
A designer at a 40-person firm is laid off on 30 September; her plan ends that day. She has until at least 29 November to elect COBRA at 102 percent of the full premium, retroactive to 1 October.² She also has until 29 November to pick a Covered California plan.⁵ She chooses a Covered California plan that starts 1 November, finds her therapist is not in its network, and asks the plan in writing for completion of covered services for her serious chronic condition under section 1373.96(b)(2); the plan may take the position that she had the option to continue her previous plan through COBRA.⁶ If it does, the October sessions are still covered by electing COBRA for one month, and she starts with an in-network therapist from November.
Q&A
Q: My employer had 12 people. A: Federal COBRA does not apply below 20 employees;¹ Cal-COBRA does, for up to 36 months at up to 110 percent.³ ⁴
Q: I missed the 60 days. A: Both COBRA windows run at least 60 days from the later of the loss or the notice — a late notice extends them.² ⁴ The Covered California window is 60 days on either side of the loss.⁵ Medi-Cal enrols year-round.⁵ Retroactive Medi-Cal for a psychiatric bill →
Q: Does COBRA cover the sessions between losing the job and electing? A: Federal COBRA coverage "must extend for at least the period beginning on the date of the qualifying event," so sessions in the gap are covered once the premium is paid, and the first premium cannot be required sooner than 45 days after election under either statute; Cal-COBRA's first payment must cover "all premiums due."² ⁴
Q: My therapist is out of network on every plan I can afford. A: Route 4 is the tool, for the listed conditions and for the statute's time limits; failing that, a superbill and out-of-network benefits. What is a superbill? →
Our therapist directory: See its current status →
If the firing itself was about your illness: Fired for my mental illness. Can I get unemployment? →
Buying a new plan with a history: Can insurance refuse me for a mental health history? →
Sources
- 29 U.S.C. §1161(b) — "Subsection (a) shall not apply to any group health plan for any calendar year if all employers maintaining such plan normally employed fewer than 20 employees on a typical business day during the preceding calendar year" — law.cornell.edu.
- 29 U.S.C. §1162 — (2) "The coverage must extend for at least the period beginning on the date of the qualifying event"; (2)(A)(i) "the date which is 18 months after the date of the qualifying event"; (2)(A)(viii) the disability extension, "any reference in clause (i) or (ii) to 18 months is deemed a reference to 29 months," "but only if the qualified beneficiary has provided notice of such determination… before the end of such 18 months"; (3)(A) the premium "shall not exceed 102 percent of the applicable premium for such period" (the "applicable premium" is defined at §1164), the flush language of (3), "any reference in subparagraph (A) of this paragraph to '102 percent' is deemed a reference to '150 percent' for any month after the 18th month of continuation coverage," and "In no event may the plan require the payment of any premium before the day which is 45 days after the day on which the qualified beneficiary made the initial election" — law.cornell.edu; 29 U.S.C. §1165(a)(1)(B)–(C) — the election period "is of at least 60 days' duration" and "ends not earlier than 60 days after the later of" the loss of coverage or the notice — law.cornell.edu.
- Department of Managed Health Care, Keep Your Health Coverage (COBRA) — "Cal-COBRA applies to employers and group health plans that cover from 2 to 19 employees"; "Cal-COBRA — up to 36 months"; "If Federal COBRA was 18 months, 18 more months of Cal-COBRA is available"; "You have 60 days after being notified to sign up"; "After you send in your enrollment form, you have 45 days to pay your first premium"; the notice and Help Center sentences as quoted; and, under "Why would an employee not qualify to enroll in Cal-COBRA?", "If the employee is covered by a self-funded plan" and "If the employee is covered by an out-of-state plan" — dmhc.ca.gov.
- Cal. Health & Safety Code §1366.27(a)(1) — continuation to "the date 36 months after the date the qualified beneficiary's benefits under the contract would otherwise have terminated because of a qualifying event" — california.public.law; §1366.24(b) — election "within the 60-day period following the later of (1) the date that the enrollee's coverage under the group benefit plan terminated or will terminate by reason of a qualifying event, or (2) the date the enrollee was sent notice," the first premium "within 45 days of the date the qualified beneficiary provided written notice" of the election, and "the first premium payment must equal an amount sufficient to pay any required premiums and all premiums due" — california.public.law; §1366.26 — "not more than 110 percent of the applicable rate charged for a covered employee or, in the case of dependent coverage, not more than 110 percent of the applicable rate charged to a similarly situated individual under the group benefit plan," and "no greater than 150 percent of the group rate after the first 18 months" for a qualified beneficiary disabled under the Social Security Act — california.public.law; §1366.21(d)(2) — the qualifying event of termination or reduction of hours "except that termination for gross misconduct does not constitute a qualifying event"; (b) and (e) the "2 to 19 eligible employees" test, measured "on at least 50 percent of its working days during the preceding calendar year" — california.public.law.
- 10 Cal. Code Regs. §6504 — (a)(1)(A) loss of minimum essential coverage as a triggering event; (f)(1) "60 days before and after the date of the loss of coverage to select a QHP"; (c) no special enrollment period for a voluntary termination of coverage or (c)(1) a loss caused by "failure to pay premiums on a timely basis," "except for circumstances in which an employer completely ceases its contributions to COBRA continuation coverage or government subsidies of COBRA continuation coverage completely cease" — law.cornell.edu; Covered California, When can I apply? — "Medi-Cal enrollment is also year-round" — coveredca.com.
- Cal. Health & Safety Code §1373.96 — (b)(2) "The completion of covered services shall be provided by a nonparticipating provider to a newly covered enrollee who, at the time the enrollee's coverage became effective, was receiving services from that provider for one of the conditions described in subdivision (c)"; (c) the conditions, including "a serious chronic condition," and (c)(2)(B) completion "shall not exceed 12 months from the contract termination date or 12 months from the effective date of coverage for a newly covered enrollee"; (e)(1) "If the nonparticipating provider does not agree to comply or does not comply with these contractual terms and conditions, the plan is not required to continue the provider's services"; (j) "Except as provided in subdivision (l), this section does not apply to a newly covered enrollee who is offered an out-of-network option or to a newly covered enrollee who had the option to continue with their previous health plan or provider and instead voluntarily chose to change health plans" — california.public.law.
- 29 U.S.C. §1163(2) — the qualifying event of "The termination (other than by reason of such employee's gross misconduct), or reduction of hours, of the covered employee's employment" — law.cornell.edu.
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