How long can a disabled child
stay on parents health insurance?

CA law allows your incapacitated 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 upon attainment of the limiting age [26 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:

   (1) Incapable of self-sustaining employment by reason of a physically or mentally disabling injury, [AB 88] illness, or condition.

   (2) Chiefly dependent upon the policyholder or subscriber for support and maintenanceWikipedia Child Support – Maintenance * MaintenanceCA Insurance Code § 10278    §10277    for Group Policies Self Insurance Plans §10124  10118

chiefly dependent”  to mean 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., 74 Ct. Cl. 633, 636 (1932), 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.

Learn More ⇒  Odlin v. U.S.

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Proofs Required for Disabled Child
Proofs Required for Disabled Child – If you have other questions – Please post in the ask a question area below

 

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

Blue Shield Dependent Definition - Disabled
Blue Shield Dependent Definition – Disabled
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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.

Click here for Guaranteed Issue Health Insurance – ACA ObamaCAre
No Medical Questions asked – No Pre-X
Quotes in CA or Nation Wide.

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

Email us your questions.

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!

Links & Resources

What if employer is not subject to CA Law?

Mental Health Benefits are an essential benefit under Health Care Reform.  New Final Rules Regulations were JUST issued…

Thus, dental coverage is not included.  Dental does not ask about health, so Dental Coverage can be purchased here.

So, age 26 is not relevant, as long as the child meets the above definition and requirements of being disabled.

Dual Coverage – Which Insurance Company pays first?  Medi-Cal, SSI, SSDI?

 

tacanow.org Autism Website – Their research & Ideas

New York NYSHIP Law  findlaw.com/ny code 4305

 

FAQ’s 

Would an immediate annuity help your situation?

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Disabled Dependent Child

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Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were covered under their parents’ previous policy?
Is an over-age disabled dependent eligible to continue coverage through this new insurance carrier if they were not covered under their parents’ previous policy?
If the disabled child is eligible to continue coverage, what documentation will be required?

Proofs Required for Disabled Child
Proofs Required for Disabled Child – If you have other questions – Please post in the ask a question area below
How often will the disabled dependent child be required to re-certify this disability?

 

 

Most of what the video says is RIGHT, not grandfathering though. Let me know if you find a video more on point
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Related Pages in Dependent Definition section

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chielfly dependent

32 comments on “Disabled Children – over 26

  1. I have a 36 year old who is on SSI disability and want to know if I can add him to my policy with Harvard Pilgrim Health Care in Mass.

  2. I’m looking for information on adding a dependent and disabled child to a health insurance plan.

    The child is over 26 yrs old and disabled.

  3. I have a 26+ year old child deemed incapable of self support and receiving social security disability. I just started a new job and have been told she is NOT eligible for health care coverage.

    xxx healthcare is claiming they only have to extend coverage to those children who were in their insurance plans prior to age 26 regardless of my being a new employee.

    • Do you mean the Insurance Company is saying they won’t transfer the benefit over, from your prior employer, when you say:

      who were in their insurance plans

      Has your child been on your prior coverage?

      • See our page where we cited Insurance Code 10277d

        (d) If the employee or member changes carriers to another insurer or to a health care service plan, the new insurer or plan shall continue to provide coverage for the dependent child.

        The new plan or insurer may request information about the dependent child initially and not more frequently than annually thereafter to determine if the child continues to satisfy the criteria

  4. My son has had SSDI for 2 years and now has Medicare. He may also qualify for Medi-Cal (Medicaid)

    Would having Government or other coverage disqualify him from remaining on an individual or employer group plan from his parents?

  5. My Question is with a RETIRED California employee with a (long-term) disabled child, now age 29.

    How long can such disabled child stay on the (large employer – quasi-govt facility) company plan?

    • Our SAMPLE Evidence of Coverage on page b 54 provides that an employee can be covered after retirement in Section 2 d:

      d) When the Member is retired and age 65 years or older.

      Enrolled disabled Dependent children who would normally lose their eligibility under this health plan solely because of age, may be eligible for coverage if they continue to meet the definition of Dependent. See the Definitions section. Page B-57

      Definitions Section

      Employee — an individual who meets the eligibility requirements set forth in the Group Health Service Contract between Blue Shield and the Employer.

      See Page B 71 for the rules for dependents. Same as above.

      To know for certain, we need to see YOUR Evidence of Coverage and Group Service Agreement – Contract, otherwise is a SWAG answer.

      COBRA would be available, Heaven forbid if the employee passes away. There is also guaranteed issue ObamaCare. Get Quotes in CA. If the child qualifies, there is Medi-Cal, Medicaid.

  6. If my daughter who has documentation of her disability and its eligible for my health insurance and vision insurance will she also be able to get dental insurance even though the dental company denied the claims saying she was too old, but yet I pay for her health insurance, dental and vision?

  7. What if disabled child lives with father, and pays majority of support, but medical insurance is paid by mother through employer.

    Child will be 26 next March.

    Each parent meets only one requirement.

    Can child still be covered by mother after age 26?

    • I believe so. Both of you are still the parents. The child is still dependent on his/her parent (s)

      I’m out of country. If you haven’t resolved this with your employer’s insurance company, email me mid May

  8. What happens when the parents no longer work for an employer, or they pass away, whose coverage the disabled child – Bi Polar, is covered by?

    I like the coverage provided by Shell Oil and don’t want anything else, it would be inferior coverage.

  9. What happens if a disabled dependent over 26 gets married? Does the parents’ coverage for that person end?

    I can’t seem to find an answer to this. (California resident).

    • Good question. Is the disabled person still “chiefly dependent” on the policy holder, see above? If you do lose coverage, that would give you a special enrollment into ACA – get quotes here.

      What Insurance Company are we talking about? I can then pull the forms and proofs for that specific company.

      While this page is very popular 189 hits in the last 30 days, no one is buying Insurance from me and thus I haven’t kept up posting the revised forms. I’m happy to when asked.

      • Yes, she is “chiefly dependent” on her parents’ insurance for lifelong medical care.

        The policy holder is Anthem Blue Shield/blue Cross.

        She also received SSI benefits.

        • Please read again, at least 3 times, what chiefly dependent means. It doesn’t mean how much she needs or uses the insurance, but if her parents are supporting & maintenance for her. Please review the footnotes above that I’ve just added.

          Now that she’s married, is her husband supporting and providing maintenance for her?

          If she has SSI that provides around $1,000/month for support. Are her parents providing more than that? In addition, SSI automatically gives her Medi-Cal coverage.

          In CA telling me Blue CrossBlue Shield means nothing. They are two separate companies.

          Please send a copy of her ID card. Then I will know and can get further details. I will not post any PHI – Protected Health Information. If I do post the ID card, I will blot that out.

          • Thanks for the ID card. The plan your friend has is not one that I’m an authorized agent for. Please have her or her parents log into their “member portal” and then you can review the actual EOC full policy and the forms that BC/BS requires to prove disability. Also you can check the definition of dependent and from what I can tell in general, being married doesn’t disqualify a child. I’m concerned about “chiefly dependent.” Please review the page above again, as I just updated it.

  10. My daughter became disabled and unable to support herself at age 27.

    She had already been terminated from my company plan (a CA plan) at age 26.

    Might there be any possible way I can get her back on my CA Employer Coverage?

    • Near as I can tell, the law lets coverage end at age 26. Here’s clarification in Blue Shield’s Group plan

      A Dependent child who reaches age 26 becomes ineligible on the day before his or her 26th birthday, unless the Dependent child is disabled and qualifies for continued coverage as described in the definition of Dependent.

      I don’t see a way to get her on your bosses coverage. She wasn’t disabled prior to age 26.

      How about an Individual Plan? Free Quotes

      Cal or COBRA?

      SSI?

      Medi-Cal

      SSDI

      Medicare?

      • Doesn’t the obama care plan (Covered CA) depend on your income?

        I have a niece (>27yo) who is also low income and without a job and covered CA only allowed her to get a medi-Cal policy.

        We are hoping for fewer exclusions and more coverage choices

        • ACA – Obama Care – Covered CA only asks for your income if you want subsidies, tax credits to pay for your premiums. If you use our quote engine, you can get quotes both with and without subsidies.

          Here’s the income chart to see what enhanced silver level you might get, Medi-Cal, subsidies, etc. Again, if you don’t want subsidies, don’t ask for them. No one can force you to take Medi-Cal.

          Here’s what I have on the benefits for Medi-Cal. I don’t get paid to do Medi-Cal. If you find something about benefits that I don’t have, please post it to help your fellow website visitors.

          All new insurance plans, must have these 10 essential benefits. ACA wanted to standardize shopping around for plans, so the only real choices are doctor lists, metal levels and insurance company service – reputation.

          Do we have a special enrollment period for your daughter to get coverage now? Otherwise we have to wait till 11.1.2017 for Open Enrollment to get a plan for 1.1.2018.

  11. Do you have a sample letter of certification that I might provide to my physican? My father is employed by the UC system and I live in New Orleans so my physician may not be accustomed to preparing the certification letter.

  12. Hi,

    I understand that CA law allows your incapacitated or disabled child over 26 to remain on the parents group or individual policy, indefinitely. Where could I find out if my son, a Massachusetts resident, would be covered?

    Thanks SO much.

    Sue O

    • The first thing to check is your actual evidence of coverage – full policy. Here’s a specimen.

      It doesn’t look like Massachusetts has this feature. NCSL.Org

      Mass. Gen. Laws Ann. Ch. 175 § 108 allows dependents to stay on their parent’s coverage for two years past the age of dependency or until age 26, whichever occurs first, or without regard to age if they are incapable of self-sustaining employment due to disability.
      Young adults ages 19-26 are eligible for lower-cost insurance coverage, tailored to meet their needs, offered through the Commonwealth Health Insurance Connector. Reform summary and fact sheet, PowerPoint presentation.

      ACA Obamacare is guarantee issue. Why not just get him his own policy?

      Is your son on your policy now?

      It appears to be optional in your state, not mandatory.

      If your adult ‘child’ is mentally or physically incapable of earning his or her own living, the
      family’s private health insurance may offer Adult Disabled Dependent Coverage. You need to
      contact your insurance company to find out: 1) if this is an option, 2) the documentation they
      require from your child’s physicians, and 3) if there is an extra premium. fcsn.org

      See page 26 of a CA Individual Specimen Policy for the rules to qualify and availability.

      With Guaranteed Issue under ACA I don’t think the feature is that meaningful. Is there something I’m missing? It’s not like there a a family rate and no charge for the child, right?

  13. In the past, we were able to enroll disabled dependents with proof of prior coverage and documentation of disability, but Blue Shield says that they will only cover disabled dependent children already enrolled on our group plan that happen to age out.

    ….. ***We will answer your question on our new page.

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