Disabled Adult Children can stay on Parent’s Health Plan past age 26

California Law – Disabled Child – Health Insurance 

CA law allows your incapacitated, handicapped, mentally ill or #disabled child over 26 to remain on the parents group or individual policy, indefinitely, as long as they were disabled before that.

• An individual or group health insurance [“Health Insurance” … shall mean a  policy that provides coverage for hospital, medical, or surgical benefits. ^§106 ]  policy that provides that coverage of a dependent child shall  terminate when the child reaches  age 26 under ACA for dependent children specified in the policy, shall also provide that attainment of the limiting age shall not operate to terminate the coverage of the child while the child is and continues to meet both of the following criteria:
  • Incapable of self-sustaining employment by reason of a physically or mentally disabling injury, [AB 88] illness, or condition.
  • Chiefly dependent upon the policyholder or subscriber for support and maintenance.  ^{Wikipedia Child Support –  Maintenance * CA Insurance Code § 10278 *  §10277  * for Group Policies Self Insurance Plans §10124  10118}

FAQ’s

• Before asking us about this law or if you qualify.
  • Please read the law above THREE times and the definition of chiefly dependent  below
  • Ask your employer’s HR department for the relevant forms and a copy of your evidence of coverage
    • For Individual & Family, ask your current broker or Insurance Company to send you the Disabled Dependent Certification and Evidence of Coverage.
• Review the FAQ’s
  • What about getting disability income protection for the parents & caretakers?
  • Double checking if your child qualifies to stay on your plan? 
  • What about when employee retires?
  • Retirement?  Medi Cal – Medicaid?
  • COBRA – CAL COBRA when parent retires or quits job? 
  • I’m changing employers and/or my employer is going with a new Insurance Company
  • Same question…
  • Self Insured Plans?
  • Making changes outside of Open Enrollment?
  • Dual Coverage – Medi Cal?
  • Would other coverage prevent one from getting dependent coverage under this rule?
  • I don’t understand all this and I need private tutoring, education or research, can we arrange that?
  • Getting coverage if not on plan prior to age 26?
  • How to get documents from the US Department of Labor  – ERISA
  • Must the Insurance Company give me notice that they won’t be coverage my child after age 26?
    • Yes, see CA Insurance Code 10277 3 B  

What does #ChieflyDependent mean?

“Chiefly dependent”  means that the person receives fifty per cent or more of his/her support from his/her parent(s), the insurance contract itself does not define “dependent.” The United States Court of Claims held in Odlin v. U.S., ^NY.Gov * ^{Covered CA}  that “chiefly dependent” does not have an explicit definition but rather “each case…must stand upon its own particular facts, and that no hard and fast rule can be laid down arbitrarily fixing the value of property, or the amount of income received…as entirely determinative of the question as to whether [a person] is ‘dependent’ within the meaning of the law.”

While the company’s interpretation of the phrase “chiefly dependent” doesn’t appear to be unreasonable, only a court of competent jurisdiction may make a conclusive determination.   ^{Odlin v. U.S. New York State Analysis *} 

IRS Definition of Dependent section §152.  *  IRS Interactive Assistant * IRS Publication 501 on Dependents

If your child is dependent on you, consider life insurance to take care of your child when you are gone. Disability in case you get ill and can’t work and Long Term Care, in case you can’t take care of yourself.

In Covered CA, (we are authorized agents) there may be issues with subsidies – MAGI Income.

Considering that everything is guaranteed issue, with no Pre X starting 1.1.2014, I didn’t  think this page would be relevant anymore, but it gets a ton of hits!

FAQ’s 

• Only disabled say age 25 or after 26?
• Does it matter if it’s Mother or Fathers Employer?  Who is child dependent on?
• Marriage?

Excerpt from “typical” Group plan:

4) If coverage for a Dependent child would be terminated because of the attainment of age 26, and the Dependent child is disabled and incapable of self-sustaining employment, Benefits for such Dependent child will be continued upon the following conditions:

a) the child must be chiefly dependent upon the Subscriber, spouse, or Domestic Partner for support and maintenance;

b) the Subscriber, spouse, or Domestic Partner must submit to Blue Shield a Physician’s written certification of disability within 60 days from the date of the Employer’s or Blue Shield’s request; and

c) thereafter, certification of continuing disability and dependency from a Physician must be submitted to Blue Shield on the following schedule:

i. within 24 months after the month when the Dependent child’s coverage would otherwise have been terminated; and

ii. annually thereafter on the same month when certification was made in accordance with item (1) above. In no event will coverage be continued beyond the date when the Dependent child becomes ineligible for coverage for any reason other than attained age.  * [See also Conditions of Enrollment Page B 56 *  Dependent Definition Page B 70] ^EOC

Get the EOC, Evidence of coverage FULL Policy  from your own Insurance Company, HR, # on back of your ID Card  and see what it says!   Visit our webpage on  EOC, Plain Language, etc. 

FAQ’s 

What about #Selfb Insured Plans?

• Answer: What does the evidence of coverage – EOC say?
•  
• ADA NCBI.NLM.NIH.gov
• CA Department of Insurance does not regulate Self Insured Plans Insurance.CA.Gov
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