Employer Groups
Definition of #Dependent

(e) “Dependent” means the spouse or registered domestic partner, or child, of an eligible employee, subject to applicable terms of the health benefit plan covering the employee, and includes dependents of guaranteed association members if the association elects to include dependents under its health coverage at the same time it determines its membership composition pursuant to subdivision (s).

FYI IRS Section 152 Definition of Dependent

(f) “Eligible employee” means either of the following:

(1) Any permanent employee who is actively engaged on a full-time basis in the conduct of the business of the small employer with a normal workweek of an average of 30 hours per week over the course of a month, in the small employer’s regular place of business, who has met any statutorily authorized applicable waiting period requirements… ^{Legislature.Gov} *  CA Insurance Code §10853

• See also the Employer Administrative Manual for the relevant Insurance Company!
  • CA Insurance Code 10277.
    • (a) A group health insurance policy that provides that coverage of a dependent child of an employee or other member of the covered group shall terminate upon attainment of the limiting age for dependent children specified in the policy…
    • (b) The insurer shall notify the employee or member that the dependent child’s coverage will terminate upon attainment of the limiting age … The insurer shall send this notification to the employee or member at least 90 days prior to the date the child attains the limiting age. …
      • You need this certification to qualify for Special Enrollment into an Individual Plan – get quotes 
• When a dependent loses coverage, there is Cal COBRA or Individual Plans.
• College attendance or student status is no longer an issue! ^{((Obama’s Plan SEC. §2714(a). EXTENSION OF DEPENDENT COVERAGE. FACt Sheet  ,  Blue Cross Specimen Individual Policy   * consumer notice   *  College Coverage?  29 CFR § 2590.715-2714 – Eligibility of children until at least age 26}  
  • FAQ – Our son is on Medi-Cal in LA County; will be moving to Berkeley (Alameda County?) in August.  Will he lose his Medi-Cal coverage if he signs up for SHIP…or more accurately, does not opt out of SHIP?  He is not our dependent and is over age 26…on Medi-cal for more than three years.
    • I presume you are talking about the Student Health Insurance Plan at Berkeley, right?1st off, we no longer deal with 3rd parties for competent adults. Your son will have to post his questions on our website, this may be done anonymously, contact UC Berkeley or Medi Cal for any further assistance.2nd Medi Cal nor Covered CA pay us a nickel for helping people with Medi Cal. How about giving us a shot at your business?If your son qualifies for Medi Cal, there is no prohibition on having other coverage. The other coverage would simply be primary or pay first. See webpage above.There may be a problem if he likes his Medi Cal HMO as he would need to change to fee for service, when he has other coverage.Please note, changes must be reported to Medi Cal within 10 days.Does your son have an online account with Medi Cal Los Angeles?
  • Young Adults and the Affordable Care Act: Protecting Young Adults and Eliminating Burdens on Businesses and Families FAQs  DOL
    • Obama White House FAQ’s
    • Health Care Insider FAQ’s

• At age 26 check out:

  • Get FREE CA Quotes under Health Care Reform
  • COBRA & California Cal-COBRA 36 months total coverage
  • Disabled Adult Children – over 26 – stay on parents insurance
    • Loss Ratio is higher for kids on parent’s plan vs those who have their own coverage Washington Post
  • Anthem Blue Cross 9/1/2010 FAQ Bulletin

Dependent Definitions
Individual & Family Policy 

• Dependent eligibility
  • To be eligible for coverage as a Dependent, the individual must meet all eligibility requirements listed above, as well as certain Covered California Dependent eligibility requirements. The individual must:
    • Be listed on the enrollment form completed by the Subscriber; and
    • Be the Subscriber’s spouse, Domestic Partner, or be under age 26 and the child of the Subscriber, spouse, or Domestic Partner. [no requirement to be on tax return!]
      • For the Subscriber’s spouse to be eligible for this plan, the Subscriber and spouse must not be legally separated.
      • For the Subscriber’s Domestic Partner to be eligible for this plan, the Subscriber and Domestic Partner must have a registered domestic partnership.
      • “Child” includes a stepchild, newborn, child placed for adoption, child placed in foster care, and child for whom the Subscriber, spouse, or Domestic Partner is the legal guardian. It does not include a grandchild unless the Subscriber, spouse, or Domestic Partner has adopted or is the legal guardian of the grandchild.
      • A child age 26 or older can remain enrolled as a Dependent if the child is disabled, incapable of self-support because of a mental or physical disability, and chiefly dependent on the Subscriber for economic support.
        • The Dependent child’s disability must have begun before the period he or she would become ineligible for coverage due to age.
        • Blue Shield will send a notice of termination due to loss of eligibility 90 days before the date coverage will end. The Subscriber must inform Covered California of the Dependent’s eligibility for continuation of coverage within 60 days of receipt of this notice in order to continue coverage.
        • The Subscriber must submit proof of continued eligibility for the Dependent at Blue Shield’s request. Blue Shield may not request this information again for two years after the initial determination. Blue Shield may request this information no more than once a year after that. The Subscriber’s failure to provide this information could result in termination of a Dependent’s coverage.  ^{Blue Shield EOC} *
• Note though that for Covered CA subsidies – it goes by whose on the tax return!!!
• Dependent Parents
  • Starting in 2023 Children can #add their dependent parents to Individual coverage * ^{APN News CA Mulling} *  ^{CA Healthline – What about Mom} *  ^{KCRA>COM News *  CA Health Care Advocates *   AB 570 Chaptered}
    • New in Benefit Year 2023: Parent and Stepparent as Dependents
    • Effective January 1, 2023, a new California law expands the definition of “dependent” for the purposes of enrollment in a Qualified Health Plan (QHP), to include a parent or stepparent of a qualified consumer. Rules for this benefit include that a dependent parent or stepparent must:
      • Meet the definition of a “Qualifying Relative” under Internal Revenue Service (IRS) rules.
        • In general, a dependent parent or stepparent is a Qualifying Relative when their annual gross income is very limited (e.g., $4,300 for 2021 tax year), and the primary taxpayer provides over one-half of the parent or stepparent’s total support during the tax year and claims them as a tax dependent. IRS Section 152
        • Live in the health plan’s service area – carriers will be required to provide coverage if the qualifying dependent lives in the carrier’s service area.
        • Be part of the same tax household as the adult child or their spouse who is the primary tax filer.
        • Be enrolled with their adult child or stepchild in the plan – the enrolled adult child can enroll their parents or stepparents in the same plan but cannot enroll their in-laws unless their spouse is also enrolled in the plan.
        • Be enrolled with their adult child or stepchild in the plan – the enrolled adult child can enroll their parents or stepparents in the same plan but cannot enroll their in-laws unless their spouse is also enrolled in the plan.
        • Not be eligible for Medi-Cal.
        • Not be eligible for Medicare, enrolled in Medicare, or identified as enrolled in Medicare through the Federal Data Services Hub.
      • Additional questions regarding the IRS rules should be referred to a tax professional.
        • Please note: Qualified Dental Plans (QDP) are not included in this law. ^{Covered CA Agent Bulletin 11.22.2022} * ^{Blue Shield Bulletin} *
• When a dependent loses coverage, that would give them a special enrollment to an Individual Plan – GET QUOTE or a late enrollment into an Employer Group Plan.
• What about adult children under 26?  For Covered CA Subsidies?
  • Adult child up to age 26 are eligible for Coverage through their parents  plan.  However if they are  paying their own taxes, they are not anyone’s tax  dependent, they do not count  towards household income, – MAGI.   Then the adult children could qualify for their own coverage in Covered CA.
  • In some cases, it might be an idea to exclude dependents from coverage on a group plan, so that the spouse and children can qualify for Covered CA subsidies.  Thus avoiding the the Family Glitch?
• Learn More⇒
  • Kaiser Health News 11.8.2013
  • Our Webpage on the Family Glitch?
  • Health Insurance Court Order
    • Right of Non Custodial Parent to Obtain Medical Information  (Family Law Code 3751.5)
  • Specimen Health Reform Individual Platinum Policy – Eligible Dependents Page 25
  • ‘It’s probably not worth it:’ Keeping your kids on your health insurance could end up costing them more   
  • Adding a Parent or Stepparent as Dependents on your Covered California Application  

When, How to add #Newborn Coverage? 
What is 30 days of Coverage?

Be sure to check the EOC Evidence of Coverage of YOUR policy!

Here’s excerpts of a sample Individual ACA Health Reform Compliant Policy:

Newborns are covered during the first thirty-one (31) days from birth and Adopted Children are covered during the first thirty-one (31) days from the date the Subscriber, enrolled spouse, or enrolled Domestic Partner is granted the right to control health care for an Adopted Child.   Refer to the part YOUR ELIGIBILITY for additional information about coverage of Newborns and Adopted Children ^{Specimen Policy Page 20}

Newborn and Adopted Child Coverage Newborn and adopted child(ren) of the Subscriber or the Subscriber’s spouse will be covered for an initial period of sixty (60) days from the date of birth or adoption. Coverage for Newborn and adopted child(ren) will continue beyond the sixty (60) days, provided the Subscriber submits through us a form to add the child under the Subscriber’s Agreement. The form must be submitted along with the additional Premium, if applicable, within sixty (60) days after the birth of the child. Failure to notify us and pay any applicable Premium during this sixty (60) day period will result in no coverage for the Newborn or Adopted Child beyond the first sixty (60) days ^{Specimen Policy Page 26}

Newborn is a recently born infant within thirty-one (31) days of birth. ^{Specimen Policy Page 168} *

As long as you enroll your newborn within 30 days of birth, coverage should be effective as of your baby’s birth date, and your baby cannot be subject to a preexisting condition exclusion.

Remember, you should enroll your baby within 30 days of the date of birth. ^DOL.Gov

See rules for Special Enrollment for Individual Plans.

Why was I billed for my newborn’s charges?

No insurance will add your newborn automatically. It is your responsibility to inform your insurance company to add your newborn baby. Most insurance companies will give you 30 days after the arrival of your newborn to add them to your coverage. However, not all plans will retro your coverage back to the birth. Always check with your insurance company for their requirements. ^{sjmedicalgroup.com}

Report Changes in household within 30 days to Covered CA  Publication 5152

Forum says the rules above stand… just because insurance company gave a month of coverage, no obligation to extend period to add child.

Consumer Links

• California Insurance Company Forms & Applications
• HealthCare.Gov     White House.Gov   Affordable Health Care Act   YouTube Channel