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Disabled Adult Child


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This is a plan design issue. Many, but not all, employers permit disabled children (and other relatives) who meet the definition of tax dependent under the Code to continue coverage past age 26.

It's not a question of "can"; it's a question of "does." The only way to determine that is to review the eligibility sections of the plan document and/or summary plan description for the parent's plan.

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(1) If the plan is self-insured, the state will not matter as ERISA generally preempts state insurance law with respect to such plans. If it is a fully insured plan, the state may have a law requiring extended coverage so it does matter in that case. I should have mentioned that in my initial answer.

(2) There are varying definitions of "disabled" but it generally will include something along the lines of the child being unable to work by reason of a physical or mental handicap and being chiefly dependent on the employee for support, etc.

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  • 4 weeks later...

What happens in the case of divorce, if the child does not live with the employee (non-custodial parent), but lives with the custodial parent. Non-custodial parent provides no support and does not claim child as a dependent on their taxes. Can the disabled adult child remain on the non-custodial parent's policy?

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Again, unless there is an applicable state law, the question is not "can" but "does." The only way you can tell for sure is to review the plan document/summary plan description.

I will say that a plan design permitting an adult, nondependent child of an employee to be eligible for coverage would be HIGHLY unusual.

There may be a way to require the ex-spouse employee to cover the child through a QMCSO process but that is outside the area of my expertise and you would have to consult with an attorney who practices family law.

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  • 1 year later...

Believe it or not, this is still an open issue.  Health Plan is self-insured.  Employer is now telling me they can waive the financial issues; i.e. - claiming dependent on tax returns and providing financial support.  Employee, my ex-spouse, does neither.  Last year the request for coverage for an overage dependent was denied as the form was unsigned and the employee did NOT support the adult child, including claiming the child as a dependent on their tax returns.

Employer has indicated to resubmit medical information (a form which has a section for the doctor to complete).  Employer is requiring me (the ex-spouse of the employee - actually shareholder) to sign the form rather than the employee.

I'm thrilled if this will give the disabled adult child coverage(it's certainly much better than Medicaid), but I'm also concerned if this can actually be approved especially given the contract holder is not signing the form.

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  • 8 months later...

The insurer approved admission to a day program for treatment last summer.  (Attendance was due to mental health issues - not addiction.)  Child attended the approved number of days.  Employer terminated coverage 12/31/2018.  I am now receiving collection notices for services in 2017 and 2018, one of which is from the day program last summer.

Employer now, i.e. March 2019,  says coverage was terminated 12/31/2016.  What happens to those outstanding bills?  Is the employer responsible?  Plan is self-insured.

 

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