These temporary accommodations apply as follows:
Layoff / Furlough - applies to Dental, Vision, Accident and Cancer, Critical Illness, Hospital Indemnity, Life, Short Term Disability, Accidental Death and Dismemberment, Optional Life, and Optional Accidental Death and Dismemberment products.
Reduction in hours - applies to Dental, Vision, Accident and Cancer, Critical Illness, Hospital Indemnity, Life, Short Term Disability, Long Term Disability, Accidental Death and Dismemberment, Optional Life, and Optional Accidental Death and Dismemberment products.
- The temporary accommodations can be selected at the product level for the company or at the employee contractual class level.
- Both fully insured and Administrative Services Only (ASO) arrangements are eligible for the extension.
- During the extension, premiums must be paid according to your regular billing cycle and extended grace periods, if any. In the event that a premium is not paid during the grace period, coverage will terminate retroactively to the last date of paid coverage, and no future dates of loss or dates of service will be covered or reimbursable.
- Life and Short Term Disability compensation-based volumes and premium amounts will be based on the pre-furlough and/or pre-reduced hour period for the applicable coverage.
- Long Term Disability premiums and benefits due will be at the reduced hour amounts for the period over which those lower hours are maintained.
- The accommodations will end on the earlier of a return to normal work hours and the period stated in our temporary accommodations.
- Normal underwriting rules, contractual provisions, and any applicable regulations will continue to apply.
No. The state has indicated that employees who have been furloughed or laid off should apply for unemployment benefits. Individuals cannot receive both unemployment benefits and DBL/PFL benefits at the same time. However, if an eligible employee becomes disabled within 4 weeks of the date of separation of employment, the employee remains eligible for DBL benefits under the employer’s NY DBL policy.
The IRS has released Notice 2021-15 “Additional Relief for Coronavirus Disease (COVID-19) Under §125 Cafeteria Plans”. Under this Notice, the IRS is continuing last year’s COVID-19 relief efforts for employer-sponsored Cafeteria Plans (§125 plans under the Internal Revenue Code), and is allowing a one-time, mid-year benefits election period for 2021. These elections are limited to “qualified benefits”, which may include Guardian dental and vision products. Underwriting approval is required.
The Outbreak Period is the period from March 1, 2020 until 60 days after the end of the national emergency or another date announced by DOL in a future notice. To the extent there are different outbreak period end dates for different parts of the country, DOL and Treasury will issue additional guidance.
The Outbreak Period will now be determined on an individual-by-individual basis. Deadlines for individuals that fall within the Outbreak Period are delayed until the earlier of: (a) one year from the date they were first eligible for relief; or (b) 60 days after the end of the National Emergency.
Unknown at the present time. The end of the national emergency will be announced by DOL and Treasury in a future notice.
During the Outbreak Period, COBRA beneficiaries have extended time frames in which to make elections and to pay premium. So long as notice or premium payment is received as discussed below, COBRA coverage is retroactive to the date of the initial qualifying event or the date of the last paid premium.
COBRA provides a qualified beneficiary at least 60 days to elect COBRA continuation coverage.
Due to COVID-19, a qualified beneficiary experiencing a qualifying event during this time now has 60 days plus the Outbreak Period to make an initial COBRA election.
EXAMPLE 1: Assume that the National Emergency ends on June 30, 2021, with the Outbreak Period ending on August 29, 2021.
Qualified beneficiary experiences qualifying event on March 1, 2021. (typically would have 60 days to elect)
Since the Outbreak Period is disregarded for purposes of determining the Individual’s COBRA election period, the last day of Individual ‘s COBRA election period is 60 days after August 29, 2021, which is October 28, 2021. Premium is due 45 days from October 28, 2021 for all retro premium due .
The temporary extension serves as a stoppage of time for the standard requirements to make an election (60 days) or pay initial premium (45 days) following a qualifying event.
EXAMPLE 2: Assume that the National Emergency is ongoing.
Qualified beneficiary experiences qualifying event on April 1, 2020
Although the Outbreak Period remains ongoing, this individual will meet their one year extension limit on May 31, 2021. If COBRA is not elected by May 31, 2021 their COBRA election rights expire. If they do elect COBRA by May 31, 2021, premium from April 1, 2020 to current is due 45 days from May 31, 2021.
Qualified beneficiaries must give notice within 60 days after certain secondary qualifying events such as divorce or a dependent ceasing to qualify as a dependent, to trigger COBRA.
A qualified beneficiary who is determined to be disabled can qualify for a COBRA extension up to 29 months if notice of the disability is given within 60 days of the date of a social security determination of disability and before the end of the original 18 months of COBRA.
Due to COVID-19, a qualified beneficiary now has the earlier of one year from the date the action would otherwise have been required or 60 days plus the Outbreak Period to provide notice of a secondary qualifying event or disability. See EXAMPLE 1 & 2 above.
The initial COBRA premium is due 45 days after the date of the initial COBRA election. Due to COVID-19, a qualified beneficiary now has the earlier of one year from the date the action would otherwise have been required or 60 days plus the Outbreak Period to make their initial COBRA election, therefore has 45 days after that election to submit their initial premium payment.
All COBRA qualifying events that occur on or after March 1, 2020 are subject to the Outbreak Period extended time frames. If elected within the extended timeframe, COBRA will be retro added to the qualifying event date. If you are an Assistance Eligible Individual under your group health plan however and you are eligible for the American Rescue Plan special COBRA election period, upon timely election you may have the option to elect COBRA retroactive to your qualifying event or to commence April 1st, 2021.
Qualified beneficiaries are responsible for COBRA premium payments. Payments must be made to the employer or to the employer’s COBRA administrator. COVID-19 rules and guidance do not change how or where premiums are paid. Assistance Eligible Individuals may qualify for COBRA premium assistance for a period of time due to the American Rescue Plan Act of 2021. Refer to the ARPA Subsidy web page for more information.
Yes. Standard procedure is employers must allow COBRA premium to be paid in monthly installments. Future premium is due monthly. Due to COVID-19, COBRA beneficiaries may delay premium payment until the earlier of one year from the date payment would otherwise have been required or the end of the Outbreak Period, plus a 30-day grace period. COBRA coverage cannot be terminated during this extended period. This premium delay applies to any COBRA beneficiary currently paying premium irrespective of the date of the COBRA election.
EXAMPLE 3: Assume that the National Emergency ends on April 30, 2021, with the Outbreak Period ending on June 29, 2021.
A COBRA beneficiary made a timely initial February 2021 payment, but did not make a March payment or any subsequent payments during the Outbreak Period. As of July 1, the beneficiary made no premium payments for March, April, May, or June. Does the beneficiary lose COBRA, and if so for which month(s)?
Since the Outbreak Period is disregarded for purposes of determining timely COBRA monthly premium payments, any payments made by 30 days after June 29, 2021 (which is July 29, 2021 – the end of the grace period), for March, April, May, and June 2021, are timely, and the beneficiary is entitled to COBRA.
Note, the COBRA beneficiary is covered under the group plan during the Outbreak Period, even though some or all of the premium payments may not be received until July 29, 2020. The group plan must make retroactive payments for the period premium was eventually paid.
EXAMPLE 4: Using the same facts as Example 3, by July 29, 2021, the COBRA beneficiary made a payment equal to two months’ premiums. For how long does the beneficiary have COBRA coverage?
The COBRA beneficiary is entitled to COBRA for March and April of 2021, the two months for which timely premium payments were made. The beneficiary is not entitled to COBRA coverage for any month after April 30, 2021.
Benefits provided by the group plan that occurred on or before April 30, 2021 are covered under the terms of the plan. Benefits are not payable if incurred after April 30, 2021.
Yes. If premium payment is not made within the extended time frame, COBRA coverage terminates retroactive to the date of the last full premium payment, if any. The employer bill will be reconciled for any premium credits due.
No. To date there is no parallel guidance from any of the states with respect to state continuation provisions.
The duration of the Outbreak Period.
Section 125 and HIPAA special enrollment periods apply to Guardian group dental and vision fully insured and self-insured products.
HIPAA requires a special enrollment period in certain circumstances. These include:
- when an employee or dependent loses eligibility for coverage in which the employee or the employee’s dependents were previously enrolled. This includes like benefits provided by Medicaid and the Children’s Health Insurance Program (“CHIP”).
- when a person becomes a dependent of an eligible employee by birth, marriage, adoption, or placement for adoption.
In these circumstances, individuals must be allowed to enroll in the group plan if they are otherwise eligible and if enrollment is requested within 30 days of the occurrence of the event (or within 60 days, in the case of the special enrollment rights added under CHIP).
Under the HIPAA special enrollment period, coverage is made effective no later than the first day of the month following the special enrollment request.
In light of COVID-19, Guardian must disregard the 30- or 60- day time limit for the duration of the Outbreak Period and accept any special enrollment request.
Section 125 plans now allow employees to make the following mid-year elections during calendar year 2020 and 2021:
- make a new election, if the employee initially declined to elect employer-sponsored dental or vision coverage.
- revoke an existing election and make a new election to enroll in different dental or vision coverage sponsored by the same employer on a prospective basis.
- revoke an existing election.
This one-time, mid-year election opportunity is at the employer’s discretion and is subject to Guardian Underwriting approval.
Until further notice, Guardian underwriting must review each employer request and determine eligibility on a case-by-case basis.
No. If an employer’s request to open a mid-year election is approved by Guardian underwriting, under HIPAA special enrollment provisions, these penalties are waived if the special enrollment election is made with the 30-day election period, as extended by the Outbreak Period.
Deadline to Make an Initial Claim. Group plans may impose a 12- or 24- month deadline for claimant to file a claim. Due to COVID-19, these deadlines are extended by the Outbreak Period.
Example 5: On March 1, 2020, a member received treatment for a condition covered under the plan, but the claim was not submitted until April 1, 2021. The plan provisions require that claims be submitted within 365 days from the date the Individual received treatment. Was the claim submitted timely?
Normally this claim must be submitted by February 28, 2021. Due to COVID-19, however, these deadlines are extended by the Outbreak Period. Therefore, the last day to submit the claim is 365 days after June 29, 2020, which is June 29, 2021.
Claims Appeals. Claimants normally have 180 days to appeal a denied claim. Due to COVID-19, a claimant now has 60 days plus the Outbreak Period to appeal the denied claim.
Example 6: A claimant received a notice of a denied claim on January 28, 2020. The notice advised the claimant that there are 180 days in which to file an appeal.
Normally this claim must be submitted by February 28, 2021. Due to COVID-19, however, these deadlines are extended by the Outbreak Period. Therefore, the last day to submit an appeal is 148 days (180 – 32 days following January 28 to March 1) after June 29, 2020, which is November 24, 2020.
External Review. Guardian group dental and visions plans are not subject to federal external review
Group Claims areas have included these notices on dental and vision member EOBs as well as member adverse benefit determination and appeals notices.
Guardian offers many products and services to help protect employees’ health and financial well-being, as well as manage their absences. At a high level the benefits that could apply include:
- Critical Illness – offers the Infectious Contagious Disease Benefit rider (if included on your plan), which pays 30 percent of the lump sum critical illness benefit to insured employees in the event of a COVID-19 diagnoses that requires hospitalization for five or more consecutive days.
- Accident – a wellness benefit is payable for the COVID test and vaccine.
- Hospital Indemnity – If a covered member is admitted to the hospital for COVID-19, a Hospital Indemnity benefit, if applicable, may be paid according to the terms of the contract.
- Short Term Disability (STD) – Employees covered by a Guardian Short Term Disability plan may be eligible for benefits if they are diagnosed with COVID-19 and are sick and unable to perform the major duties of their job. Eligibility may be determined based on medical documentation and additional information received by Guardian. Some Guardian contracts include a rider, which can provide benefits in a quarantine situation as ordered by a doctor. This rider is explained in more detail in this FAQ.
- Absence Management Services –Employees may be eligible for leave under the Family Medical Leave Act (FMLA) which entitles the employee to unpaid leave when individuals or family members are ill as a result of COVID-19.
- NY and NJ Paid Family Leave and State Mandated Disability – NY and NJ released clarification that quarantined individuals are eligible for coverage. If an employer has a current NJ state-mandated temporary disability (TDB) or NY state-mandated disability benefits and paid family leave policy (DBL/PFL) with Guardian, Guardian is able to manage these claims in compliance with updated guidance from the states.
- Employee Assistance Program (EAP) Services – To help support our small business customers, we are extending our comprehensive WorkLifeMatters EAP through Integrated Behavioral Health (IBH) to all our Guardian planholders with 500 employees or less, at no cost through July 31, 2020. Learn more here. If you already have EAP services through Guardian, please check your email from IBH for helpful information and the latest program updates.
Employees quarantined due to COVID-19 may be eligible for benefits under one of Guardian’s Short Term Disability (STD) riders. After the quarantine period, if the employee is determined to be disabled due to COVID-19, benefits could be paid for the disability until the maximum period under the plan (excluding any weeks paid for the quarantine period).
Under the STD plan, employees may be eligible for benefits if they are diagnosed with COVID-19 and, as a result, are unable to perform the major duties of their job. Eligibility will be determined based on medical documentation.
The Quarantine Rider covers employees if they are placed under a doctor ordered quarantine and are unable to perform the major duties of their job. The employee must be suspected of carrying or having been exposed to an infectious and contagious disease as determined by the doctor who would then order the quarantine. The nature of quarantine and the definition to support it is determined by the Centers for Disease Control (CDC) or the U.S. Secretary of Health and Human Services.
The rider is available on the 2016 contract (DI 16) series for STD and is not available in some states.
In order to be eligible for FML, an employee or family member the employee is caring for needs to have medical documentation that certifies the individual’s condition meets the definition of a serious health condition.
Guardian will cover active virus testing and COVID vaccines under our Accident Wellness benefit as a routine exam for COVID-19 tests performed on or after 3/1/20. This benefit is not payable under the Wellness Benefit included with Critical Illness, Hospital Indemnity, and Cancer products.
In most cases, the Accident product doesn’t provide benefits for a sickness like COVID-19. However, benefits may be payable if the plan includes a hospital confinement sickness rider or a short-term disability rider that covers injuries and sickness benefits. The disability rider does not cover quarantine situations. Please read the details of policy/contract to determine if this benefit rider is included.
Guardian Critical Illness insurance now offers the Infectious Contagious Disease Benefit rider (if included on your plan), which pays 30 percent of the lump sum critical illness benefit to insured employees in the event of a COVID-19 diagnoses that requires hospitalization for five or more consecutive days. This benefit also applies to any future strains of the coronavirus that may cause severe illness and/or hospitalization, as well as any future emergence of a severe health threat caused by a contagious virus.
Yes. If a covered member is admitted to the hospital for any reason, a benefit may be paid, according to the terms of the contract. All plans pay for an initial hospital admission benefit, and many plans pay for a daily hospital confinement benefit (including Intensive Care Unit). Some plans may include benefits related to doctor office visits, diagnostic tests, prescription drug benefit, and urgent care and emergency room benefit. Please read the details of the policy/contract to determine if these benefit options are applicable.
In most cases, the Cancer product doesn’t provide benefits for a sickness like COVID-19. However, benefits may be payable if the plan includes an Intensive Care Unit rider. Please read the details of the policy/contract to determine if this benefit rider is included.
Yes. If an employer has a current NY Disability Benefit (DBL) and Paid Family Leave (PFL) policy with Guardian, all claims will be determined in compliance with updated guidance from the State. For more information on the NY COVID Paid Leave Benefits, see New York Paid Family Leave COVID-19: Frequently Asked Questions.
If an employer has a current NJ Temporary Disability Benefit (TDB) policy with Guardian, all claims will be determined in compliance with updated guidance from the State. Guardian does not currently administer NJ Family Leave Insurance (FLI) benefits. For more information on the NJ COVID Paid Leave Benefits, see NJDOL Benefits and the Coronavirus (COVID-19): What Employees Should Know.
The NY COVID-19 Paid Sick Leave would only be applicable to NY covered employees under the employer’s existing NY DBL/PFL policy. Out of State employees would not be recognized as being in NY covered employment by the NY Workers’ Compensation Board (WCB); and thereby, would not be eligible to the benefit entitlements under NY Worker’s Compensation law.
While we cannot waive the need for medical certification, we recognize the current and anticipated strains on providers and are adapting our processes to collect information verbally and electronically wherever possible.
To help ensure quick processing of claims, we highly recommend employees submit claims online at guardiananytime.com.
For disability claims, employees can enroll in our direct pay program when they submit their claims online. By submitting claims online, an employee can set up their bank account to have disability payments deposited directly.
In addition, we’re leveraging our Medical Specialist to gather medical documentation over the phone to assist with the disability claim management process. We continue to evaluate the evolving environment to adapt as needed.
Telemedicine services are health care services delivered through the use of electronic technology or media, including interactive audio or video, for the purpose of diagnosing or treating a patient, providing remote patient monitoring services, or consulting with other health care providers regarding a patient's diagnosis or treatment.
To help our customers move toward more electronic interactions in response to COVID-19, we’ve made temporary changes to our telemedicine claim practices.
For our Accident product, telemed visits are covered for any follow-up visits due to a covered accident. Members will need to provide documentation of the visit which can include a copy of their medical EOB, bill or treatment notes from that date.
For our Dental product, we offer a Guardian teledentistry service for our PPO members. They can access it at www.virtudent.com/guardianteledentistry
For our Disability products, we will evaluate the medical documentation that is available, whether through telemedicine or another provider. Each claim and medical information provided is evaluated on its own merits to ensure there is sufficient documentation to assess the disability. We will work with our customers and/or their treating providers as needed and appropriate to clarify medical information and ensure we are positioned to make accurate decisions aligned with the policy.
If a group has concern with an upcoming draft, contact us to request a stop on the draft. A stop can be processed if the payment has not been released to the bank.
We provide a teledentistry option for our PPO members who need urgent dental care. They can simply visit www.virtudent.com/guardianteledentistry to schedule an appointment. Standard plan limitations and exclusions apply
Providers and retailers are still fulfilling orders, but their hours should be checked before visiting since many have revised schedules at this time.