Dependent Coverage Issue

[Guest buhlerm]

So I'm new to forums.... we are a self insured health plan. We have a participant who has now become responsible for an unborn child (he got his girlfriend pregnant). We live in a common law state, so we have affidavit's readily available just for such an occasion. He has refused to sign, saying we should cover his soon to be dependent child, and the mother to assure our plan will soon have a healthy child:confused: I guess the thought is if she does not health coverage, then she would be at risk of delivering a baby that would not be as healthy if she did have coverage. My question is; I assume most plans would not cover this yet to be born child, but other than our plan saying that is the way it is, does anyone have any good reasons why we should not cover this child? I have plenty of reasons, but was looking for additional input. THanks.

[oriecat]

The only way for the "child" to have coverage is if the mother has coverage. If he wants coverage, then he needs to comply with the plan and put her on as a spouse, or domestic partner, however the plan is set up. If he refuses to do that, then I don't see any way to give coverage to the child until it is born, when he could then add the newborn child to the plan.

Editing because I forgot you said self-insured. Does the plan document say anything about separate dependent coverage for unborn children? (I wouldn't think so!) Just go by what the plan doc says. He can't expect more than that.

[Sandra Pearce]

Most health plans are subject to the special enrollment provisions of HIPAA. Birth of a child is a HIPAA special enrollment reason which would allow your employee to add coverage for the new dependent and that coverage is effective the date of the birth. Also this child would have to meet the plan's definition of an eligible dependent. In most plans the natural child of the employee is an eligible dependent. Proof might be required in the form of a copy of the birth certificate which would show the employee to be the father of the child.

I do not agree that the only way for a child to have coverage is for the mother to have coverage. In our health plan the common law wife of the employee would not be an eligible dependent but the natural child born to the common law wife and our employee would be an eligible dependent.

Read your plan document and/or SPD for the definition of an eligible dependent and for the provisions for enrollment.

[oriecat]

Originally posted by Sandra Pearce

I do not agree that the only way for a child to have coverage is for the mother to have coverage.  In our health plan the common law wife of the employee would not be an eligible dependent but the natural child born to the common law wife and our employee would be an eligible dependent.

I agree with that, and I realize where the confusion comes in, because I edited my message and took out a question I had. It sounds to me like the employee wants the unborn child to be covered as a dependent. What I was trying to say was that the unborn child can only be covered if the mother is covered. Maybe I misunderstood the question though, but to me that seemed to be what the employee wanted to do. Of course adding the child after birth would not be a problem, if the plan allows dependent coverage. It's just that the unborn baby cannot be seen as a dependent, therefore the mother would have to be covered at this point, IMO.

(That's why I put "child" instead of child. The employee views the unborn baby as it's child, but legally it is not yet a dependent. I had the same question once actually. I told him no, they would have to get married and cover the spouse. They were doing that anyway, so it worked out.)

[Sandra Pearce]

I started to comment on the unborn child issue but dropped it. I agree the child has to be born to have coverage.