Get FREE Instant Quotes - Including Tax Subsidy Calculation - Guaranteed Issue - No Pre-X Clause
Get FREE Instant NATIONWIDE Quotes – Including Tax Subsidy Calculation – Guaranteed Issue – No Pre-X Clause
Proofs Required for Disabled Child
Proofs Required for Disabled Child – If you have other questions – Please post in the ask a question area below

Text of CA Law mandating coverage for disabled children.
CA Insurance Code §10277.

This is a technical page, showing the actual law, see the Introduction page to coverage for disabled children.

§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, 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, illness, or condition.

(2) Chiefly dependent upon the employee or member for support and maintenance.

(b) The insurer shall notify the employee or member that the dependent child’s coverage will terminate upon attainment of the limiting age unless the employee or member submits proof of the criteria described in paragraphs (1) and (2) of subdivision (a) to the insurer within 60 days of the date of receipt of the notification. 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. Upon receipt of a request by the employee or member for continued coverage of the child and proof of the criteria described in paragraphs (1) and (2) of subdivision (a), the insurer shall determine whether the dependent child meets that criteria before the child attains the limiting age. If the insurer fails to make the determination by that date, it shall continue coverage of the child pending its determination.

(c) The insurer may subsequently request information about a dependent child whose coverage is continued beyond the limiting age under subdivision (a), but not more frequently than annually after the two-year period following the child’s attainment of the limiting age.

(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 in paragraphs (1) and (2) of subdivision (a). The employee or member shall submit the information requested by the new plan or insurer within 60 days of receiving the request.

(e) If a group health insurance policy provides coverage for a dependent child who is over 26 years of age and enrolled as a full-time student at a secondary or postsecondary educational institution, the following shall apply:

(1) Any break in the school calendar shall not disqualify the dependent child from coverage.

(2)  If the dependent child takes a medical leave of absence, and the nature of the dependent child’s injury, illness, or condition would render the dependent child incapable of self-sustaining employment, the provisions of subdivision (a) shall apply if the dependent child is chiefly dependent on the policyholder for support and maintenance.

(3)

(A) If the dependent child takes a medical leave of absence from school, but the nature of the dependent child’s injury, illness, or condition does not meet the requirements of paragraph (2), the dependent child’s coverage shall not terminate for a period not to exceed 12 months or until the date on which the coverage is scheduled to terminate pursuant to the terms and conditions of the policy, whichever comes first. The period of coverage under this paragraph shall commence on the first day of the medical leave of absence from the school or on the date the physician determines the illness prevented the dependent child from attending school, whichever comes first. Any break in the school calendar shall not disqualify the dependent child from coverage under this paragraph.

(B) Documentation or certification of the medical necessity for a leave of absence from school shall be submitted to the insurer at least 30 days prior to the medical leave of absence from the school, if the medical reason for the absence and the absence are foreseeable, or 30 days after the start date of the medical leave of absence from school and shall be considered prima facie evidence of entitlement to coverage under this paragraph.

(4) This subdivision shall not apply to a policy of

specialized health insurance,

Medicare supplement insurance,

CHAMPUS-supplement or

TRICARE-supplement insurance policies, or to

hospital-only, accident-only, or

specified disease insurance policies that reimburse for hospital, medical, or surgical benefits.

(f)

(1) Except as set forth in paragraph

(2), under no circumstances shall the limiting age under a group or individual health insurance policy that provides coverage of a dependent child be less than 26 years of age with respect to policy years beginning on or after September 23, 2010.

(2) For policy years beginning before January 1, 2014, a group health insurance policy that qualifies as a grandfathered health plan under Section 1251 of the federal Patient Protection and Affordable Care Act (Public Law 111-148) and that makes available dependent coverage of children may exclude from coverage an adult child who has not attained the age of 26 years only if the adult child is eligible to enroll in an eligible employer-sponsored health plan, as defined in Section 5000A(f)(2) of the Internal Revenue Code, other than a group health plan or policy of a parent.

(3)

(A) With respect to a child (i) whose coverage under a group or individual health insurance policy ended, or who was denied or not eligible for coverage under a group or individual health insurance policy, because under the terms of the policy the availability of dependent coverage of children ended before the attainment of 26 years of age, and (ii) who becomes eligible for that coverage by reason of the application of this subdivision, the health insurer shall give the child an opportunity to enroll that shall continue for at least 30 days. This opportunity and the notice described in subparagraph (B) shall be provided not later than the first day of the first policy year beginning on or after September 23, 2010, consistent with the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the federal Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), and any additional federal guidance or regulations issued by the United States Secretary of Health and Human Services.

(B) The health insurer shall provide written notice stating that a dependent described in subparagraph (A) who has not attained the age of 26 years is eligible to apply for coverage. This notice may be provided to the dependent’s parent on behalf of the dependent. If the notice is included with enrollment materials for a group policy, the notice shall be prominent.

(C) In the case of an individual who enrolls under this paragraph, coverage shall take effect no later than the first day of the first policy year beginning on or after September 23, 2010.

(D) A dependent enrolling in coverage under a group policy pursuant to this paragraph shall be treated as a special enrollee as provided under the rules of Section 146.117(d) of Title 45 of the Code of Federal Regulations. The health insurer shall offer the recipient of the notice all of the benefit packages available to similarly situated individuals who did not lose coverage by reason of cessation of dependent status. Any difference in benefit or cost-sharing requirements shall constitute a different benefit package. A dependent enrolling in coverage under a group policy pursuant to this paragraph shall not be required to pay more for coverage than similarly situated individuals who did not lose coverage by reason of cessation of dependent status.

(4) Nothing in this section shall require a health insurer to make coverage available for a child of a child receiving dependent coverage. Nothing in this section shall be construed to modify the definition of “dependent” as used in the Revenue and Taxation Code with respect to the tax treatment of the cost of coverage.

(Amended by Stats. 2010, Ch. 660, Sec. 2. Effective January 1, 2011.)

 

10278.  (a) An individual health insurance policy

that provides that coverage of a dependent child shall terminate upon attainment of the limiting age 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, illness, or condition.

(2) Chiefly dependent upon the policyholder or subscriber for support and maintenance.

(b) The insurer shall notify the policyholder or subscriber that the dependent child’s coverage will terminate upon attainment of the limiting age unless the policyholder or subscriber submits proof of the criteria described in paragraphs (1) and (2) of subdivision (a) to the insurer within 60 days of the date of receipt of the notification. The insurer shall send this notification to the policyholder or subscriber at least 90 days prior to the date the child attains the limiting age. Upon receipt of a request by the policyholder or subscriber for continued coverage of the child and proof of the criteria described in paragraphs (1) and (2) of subdivision (a), the insurer shall determine whether the dependent child meets that criteria before the child attains the limiting age. If the insurer fails to make the determination by that date, it shall continue coverage of the child pending its determination.

(c) The insurer may subsequently request information about a dependent child whose coverage is continued beyond the limiting age under subdivision (a), but not more frequently than annually after the two-year period following the child’s attainment of the limiting age.

(d) If the subscriber or policyholder 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 in paragraphs (1) and (2) of subdivision (a). The subscriber or policyholder shall submit the information requested by the new plan or insurer within 60 days of receiving the request.

(e) If an individual health insurance policy provides coverage for a dependent child who is over 18 years of age and enrolled as a full-time student at a secondary or postsecondary educational institution, the following shall apply:

(1) Any break in the school calendar shall not disqualify the dependent child from coverage.

(2)  If the dependent child takes a medical leave of absence, and the nature of the dependent child’s injury, illness, or condition would render the dependent child incapable of self-sustaining employment, the provisions of subdivision (a) shall apply if the dependent child is chiefly dependent on the policyholder for support and maintenance.

(3) (A) If the dependent child takes a medical leave of absence from school, but the nature of the dependent child’s injury, illness, or condition does not meet the requirements of paragraph (2), the dependent child’s coverage shall not terminate for a period not to exceed 12 months or until the date on which the coverage is scheduled to terminate pursuant to the terms and conditions of the policy, whichever comes first. The period of coverage under this paragraph shall commence on the first day of the medical leave of absence from the school or on the date the physician determines the illness prevented the dependent child from attending school, whichever comes first. Any break in the school calendar shall not disqualify the dependent child from coverage under this paragraph.

(B) Documentation or certification of the medical necessity for a leave of absence from school shall be submitted to the insurer at least 30 days prior to the medical leave of absence from the school, if the medical reason for the absence and the absence are foreseeable, or 30 days after the start date of the medical leave of absence from school and shall be considered prima facie evidence of entitlement to coverage under this paragraph.

(4) This subdivision shall not apply to a policy of specialized health insurance, Medicare supplement insurance, CHAMPUS-supplement, or TRICARE-supplement insurance policies, or to hospital-only, accident-only, or specified disease insurance policies that reimburse for hospital, medical, or surgical benefits.

(Amended by Stats. 2008, Ch. 390, Sec. 3. Effective January 1, 2009.)

This page may have been superceded by the Essential Benefits Mandate of Mental Health in the Affordable Care Act.

grandfathered health plan e employer-sponsored health plan

special enrollee as provided under the rules of Section 146.117(d) of Title 45 of the Code of Federal Regulations.

similarly situated individuals

 “dependent” as used in the Revenue and Taxation Code

Insurance Companies must give notice before terminating coverage AB 910)

Consumer Resources

Open Enrollment

Dual Coverage

Medicare Eligible

Medicare Advantage Plans

Medi Gap

599.500 CCR  Cal Pers

Other Pages in this section

6 comments on “Text of Law – Mandating coverage for disabled children §10277

    • What does the evidence of coverage – EOC say? Please send your EOC to us or at least take a photo of your ID card with your Smart Phone and send to us. We don’t post individual identifiable information. We might then be able to search and find your EOC Evidence of Coverage and it would be so much easier to show you the benefits you have in your policy.

      Pro

      The Affordable Care Act, also known as the ACA, specifies requirements and guidelines in a number of different areas that are relevant and applicable to self-funded employers. Below is a summary of these provisions.

      Disabled children who meet the requirements for enrollment, however, do not become ineligible at age 26. Providence.org

      ADA NCBI.NLM.NIH.gov

      The ADA protects against disability-based discrimination in employment, governmental and commercial activities, transportation, and telecommunications.

      ADA Title V allows bona fide insured or self insured employee benefit plans to make some health-related distinctions for risk classifications based upon, or not inconsistent with, state law.

      However, all such provisions are allowable under the ADA only if they meet the requirements of applicable state law and are not used as a subterfuge

      Disability-based distinctions involving dependent coverage will be analyzed in the same fashion as disability-based distinctions in employee coverage Cornell.edu

      The Department of Labor has instituted disability nondiscrimination regulations which may apply to those with “health factors.” The regulations are complex; setpnowskilaw.com

      Con

      CA Department of Insurance does not regulate Self Insured Plans Insurance.CA.Gov

      Self-funded Health Plans–Federal or Governmental:

      Although the business of insurance is primarily regulated by the state, a number of federal laws contain requirements that apply to private health coverage, including ERISA and HIPAA. ERISA was enacted in 1974 to protect workers from the loss of benefits provided through the workplace; and in 1996, HIPAA was motivated by concern that people faced lapses in coverage when they change or lose their jobs.

      Most self-funded health plans operate under ERISA and are health benefit arrangements sponsored by empoyers or employee organizations. Under a self-funded arrangement, the employer retains the responsibility to pay directly for health care services of the plan participants.

      In Connecticut, self-funded health plans cover approximately 50% of the privately insured citizens.

      ERISA does not require employers to establish any type of employee benefit plan, but contains requirements applicable to the administration of the plan, such as requirements for disclosure, reporting and fiduciary standards, claims and continuation coverage.

      In general, ERI[S]A preempts state laws that would regulate the operation of health plans. Therefore, any state mandates do not apply to those covered by self-funded plans. (An exception is CT’s state employee plan, which abides by state mandates by contract).

      Self-funded governmental plans such as the state employee plan or municipal self-funded plans may be exempt from ERISA but still bound to follow other federal laws, such as the federal regulations on internal and external review processes under the Affordable Care Act or the Mental Health parity and Addiction Equity Act of 2008. Ct.Gov

      Can my child with a disability be covered after the age of 26?

      If your plan is fully insured, it is regulated by state laws in addition to federal laws Pacer.org

      ERISA

      Met Life v Mass.

      Primer on ERISA pre-emption

Leave a Reply

Your email address will not be published.

wp-puzzle.com logo