California employers that offer group medical insurance often ask how they can keep a child on an employee’s health insurance plan after turning age 26. This article answers questions like this one:
My son turns 26 in May and was diagnosed with Autism several years ago. I received a notice in the mail from our insurance company that states that if the child is deemed disabled that insurance can continue. How does that work? Do you know how to navigate these waters in continuing insurance for a child 26+ that is autistic?
If you’re in this situation, you should know that an over-age disabled dependent can continue coverage with proper documentation. This excerpt from the California Insurance Code describes the criteria for an adult child to qualify as a dependent after age 26.
California Insurance Code Section 10277
(a) A group health insurance policy… shall .. not terminate the coverage of the child while the child is and continues to meet both of the following criteria:
(1) Incapable of self-sustaining employment by reason of a physically or mentally disabling injury, illness, or condition.
(2) Chiefly dependent upon the employee or member for support and maintenance.
Insurance companies, such as Anthem Blue Cross of California and Blue Shield of California require that the parent and the attending physician complete and sign specific forms. Other insurance companies, such as Delta Dental require a letter from the attending physician confirming the disability. The letter must include the child’s name and diagnosis. The attending physician is a medical doctor authorized to confirm the child’s diagnosis and disability.
Blue Shield of California Requirements
Blue Shield requires both the parent or guardian and a physician to complete a “Declaration of disability for over-age dependent child.” Parents must submit the form within 31 days before the child’s 26th birthday. A “child” includes any stepchild, legally adopted child, or foster child.
Anthem Blue Cross of California Requirements
Anthem Blue Cross’ “Handicap Dependent Certification Form” asks these questions:
- Does the contract holder claim the dependent for income tax purposes? Yes No
- Does the dependent live with the contract holder? Yes No
- If “No” to either question, please explain:
- Is the dependent currently receiving Social Security benefits? Yes No
- If “Yes,” what was the effective date? (MMDDYYYY)
- If “No,” have benefits been denied? Yes No
- Diagnosis/Prognosis — Must be completed and certified by a physician
- Diagnosis ICD–10 code(s)
- In your opinion, is the above named dependent currently incapable of self-sustained employment? Yes No
- In your opinion, will the dependent ever be capable of self-sustained employment? Yes No
- If “Yes,” provide estimated date of return to full functionality: (MMDDYYYY)
So, an adult child can stay on a parent’s small group medical insurance plan after his or her 26th birthday but he or she must meet the two-part test described above. If you’re current health insurance broker can’t assist you with this, then you may want to have Benefits Café become the agent/ broker on your group health insurance plan and we can help. Give us a call at 800-746-0045.