Continuation of Coverage for Overage Disabled Children

Transcription

1 Administrative Supplement II-D Continuation of Coverage for Overage Disabled Children Background Employees with enrolled disabled dependent children may continue coverage for these children beyond age 26 provided criteria are met under GIR Part II-C and carrier approval is obtained. The medical carrier will determine if the child is disabled at the time the application is made. Disabled children over 26 years of age who are approved for coverage under a medical plan are eligible for continued coverage under any other medical plan, the dental plan, the vision plan, the life plan, the AD&D plan and the group legal plan. If enrollment is transferred between medical or dental plans a new application is not required. Overage disabled children must have UC medical coverage in order to be enrolled in UC s dental, vision, legal, AD&D or life plans. Carriers may request periodic proof of disability. Coverage may continue under a plan as long as the child is continuously disabled, meets all other eligibility requirements listed above and the Employee is covered under the plan. Upon request, employees must provide verification of income tax dependency or verification of disabled dependent s eligibility for Social Security Income or Supplemental Security Income as a disabled person. Legal wards are not eligible to continue coverage beyond age 18, even if disabled. The following outlines the continuation of coverage process for disabled dependent children attaining age 26 (age-ins), for newly hired employees initial enrollment of overage disabled children, and the addition of newly eligible overage disabled children of existing employees. The attached charts summarize eligibility requirements as well as carrier procedures. Location, carrier, and employee responsibilities in the process also are included. 1

2 Administrative Supplement II-D General Overage disabled dependent children may only be added to UC-sponsored plans in the four scenarios listed below. Overage disabled children may not be added during Open Enrollment. Age-in Process (applies to dependents currently covered who are disabled): 1. Carrier sends notification of disenrollment, and overage disabled continuation information to employee two to three months before the child s 26 th birthday. 2. Employee applies to medical plan carrier before the child s 26 th birthday in accordance with carrier s requirements. Carrier is responsible for providing certification documents to member. Employee obtains information as requested on the form (e.g., treating physician s report, lab tests, etc.) and returns to carrier for determination. 3. Carrier determines disabled status. 4. Carrier sends written approval/denial notification to employee with a copy to the Benefits Manager. 5. Location relies on letter from carrier to update system to ensure continuation of child s coverage if approved; if denied, automatic de-enrollment should take place as scheduled (Benefits Manager should verify). New Hire Process (applies to disabled dependents over age 26 on employee s date of hire): 1. Employee provides, to the benefits office, proof of prior medical coverage enrollment, plus the date and reason coverage terminated. (For example, a letter from the former employer or proof of Medicare/Medi-Cal coverage). 2. Employee applies to carrier within 31-day PIE for determination of disabled status of overage child. 3. Carrier determines disabled status of overage child. 4. Carrier sends written approval/denial notification to employee with a copy to the Benefits Manager. 5. Employee submits enrollment via form (UPAY850) to enroll disabled child within 31 days of carrier approval notification. 6. If approved by carrier, coverage is retroactive to the first day of the new hire PIE. Involuntary Loss of Coverage (ILOC) (applies to eligible disabled child over age 26 who has involuntarily lost coverage under other coverage): 2

3 Carrier Responsibilities Administrative Supplement II-D 1. Employee provides, to the benefits office, proof of loss of prior medical coverage enrollment (to include Medicare, Medi-Cal, or COBRA). 2. Employee applies to carrier within 31-day PIE for determination of disabled status of overage child. 3. Carrier determines disabled status of overage child. 4. Carrier sends written approval/denial notification to employee with copy to the Benefits Manager. 5. Employee submits enrollment form (UPAY850 or UBEN100) with copy of carrier s written approval of disability and proof of loss of other coverage to enroll disabled child within 31 days of carrier approval notification. 6. If approved by carrier, coverage is retroactive to the first day of the PIE. Newly Acquired Overage Disabled Child/Step-Child (Applies to an overage disabled child who is newly acquired as a Family Member through marriage/domestic partnership or adoption) 1. Employee provides, to the benefits office, proof of continuous prior medical coverage enrollment (For example, a letter from the former employer or proof of Medicare/Medi-Cal coverage) 2. Employee applies to carrier for determination of disabled status of overage child within 31-day PIE that begins on the date the employee acquires the new dependent. 3. Carrier determines disabled status of overage child. 4. Carrier sends written approval/denial notification to employee with copy to the Benefits Manager. 5. Employee submits enrollment via form (UPAY850 or UBEN100) to enroll disabled child within 31 days of carrier approval notification. 6. If approved by carrier, coverage is retroactive to the first day of the PIE. 1. Provide application and/or information on required documentation necessary to determine disability upon request of employee. 2. Review application/medical documentation to determine disabled status. 3. Send written notification of approval/denial to employee. 4. Copy the appropriate UC Benefits Office on all approval/denial letters sent in response to application to continue coverage for disabled children. Anthem will notify under separate cover. 3

4 Employee Responsibilities Benefit Office Responsibilities Administrative Supplement II-D 5. If possible, carriers will indicate in approval letter that the employee should contact local Benefits Office within 31 days of notification to ensure continuation of coverage or eligibility for enrollment. 6. Conduct periodic review to determine disabled status and continuing eligibility; notify appropriate UC Benefits Office if coverage is terminated. 1. Apply for continuation of coverage before the child s 26 th birthday in accordance with carrier requirements. 2. Provide required medical documentation as proof of disability. 3. Ensure continuous medical coverage beyond the age of 26. If the employee is enrolling as a new hire or enrolling a newly eligible disabled child, employee should ensure that the disabled child has been continually enrolled in medical coverage since age Contact local Benefits Office within 31 days of carrier approval notification to ensure continuation of coverage. 5. Qualify under GIR 1002.B., 2102.B., or 6002.B. 6. Upon request, provide annual tax verification documentation, or proof of eligibility for Social Security Income or Supplemental Security Income (SSI) as a disabled person. 1. Counsel employees on eligibility requirements and procedures for continuation of coverage on overage disabled children. 2. Upon receipt of carrier approval, update system to ensure continuation of coverage beyond age Set appropriate disabled indicator flag in child s record at local payroll system. 4

5 Carrier Certification Process For Overage Disabled Children Administrative Supplement II-D Anthem Blue Cross Health Net Kaiser Western Health Advantage Initial Certification Anthem will notify subscriber that the child will be termed first of the month following the 26 th birthday by sending the Overage Dependent Letter 60-days prior to the termination date. Anthem notifies the client via to the location Benefits Manager. If request is by a retiree, Anthem notifies RASC via . Subscriber submits the following to Anthem: Completed Overage Dependent Letter and Disabled Dependent Certification Form. The forms can be found on the Group Admin Site or Anthem/UC Microsite Health Net will notify subscriber that the child will be terminated on their 26 th birthday. A completed Health Net Disabled Dependent Certification (DDC) form must be submitted. Health Net will review the completed form to verify all Health Net criteria are met. The dependent will be enrolled by UC once review is completed/approved. Subscriber completes Disabled Dependent Enrollment Application. Once form is reviewed, status of approved/disapproved is mailed by Kaiser to subscriber and to UC. WHA notifies the subscriber that a covered dependent child will be terminated at least 90 days in advance of the covered dependent's 26th birthday. The subscriber must submit confirmation to WHA that the covered dependent child is eligible for disabled status because he/she is chiefly dependent upon the subscriber for support and is incapable of self-sustaining employment by reason of a physically or mentally disabling injury, illness or condition incurred prior to age 26. Subscriber needs to submit the WHA Declaration of Disability form to WHA within 60 days of receiving the termination notice for the covered dependent child. 5

6 Administrative Supplement II-D Anthem Blue Cross Health Net Kaiser Western Health Advantage Re-Certification Anthem will send subscriber Overage Dependent Letter 60- days prior to the termination date. Anthem notifies the client via to the location Benefits Manager. If request is by a retiree, Anthem notifies RASC via . Subscriber submits the following to Anthem: There are 2 types of Disabled dependent certifications: 1. Permanent = one certification only. No recertification required. 2. Temporary = requires recertification. Usually certified for either one or two years. This is really a case by case basis, depending on the diagnosis and prognosis of the individual dependent. Some are certified for a little as six months. Kaiser Permanente verifies disabled dependent eligibility every 2 years if permanent, and requires recertification based on the date of temporary status if temporary. Two years after the covered dependent has been certified, WHA may request proof annually. Completed Overage Dependent Letter and Disabled Dependent Certification Form. The forms can be found on the Group Admin Site or Anthem/UC Microsite. 6

7 Anthem Blue Cross Health Net Kaiser Administrative Supplement II-D Western Health Advantage Paperwork Received and Certification Approval When Anthem receives the completed documentation, Anthem will review the request within 5 business days. If the request is approved, Anthem will notify the subscriber, by way of approval letter to the subscriber s residence and update the Anthem eligibility system. If the request is approved, Anthem notifies the client via to the location Benefits Manager. If it for a retiree s dependent, Anthem notifies RASC via . This is so the appropriate disabled indicator flag can be added in the child s record at the local payroll system. Health Net will notify UC of approval. Once form is received and reviewed, status of approved/disapproved is mailed by Kaiser to subscriber and to UC. Upon confirmation that the covered dependent child is eligible for disabled status, WHA removes the pending termination date and adds a Disability Indicator in its system notating that the overage dependent child is an eligible dependent. WHA sends confirmation to UC when a covered dependent is certified for disabled status. Current ID card and benefit information is valid. The dependent child does not experience a lapse in coverage. If the documentation Anthem receives is incomplete, Anthem will not send a request for additional information. Anthem will send a termination letter to subscriber notifying of the end date of coverage. If the subscriber provides the completed information within 60-days of the end date, Anthem will reopen the request and review the information for certification. 8

8 Administrative Supplement II-D Paperwork Declined Blue Shield of California If request is denied, Anthem will send a termination letter to the subscriber s residence notifying of the end date. Anthem will notify the client of any deleted dependents via to the location Benefits Manager. If request is by a retiree, Anthem notifies RASC via . Health Net Should a request be denied, Health Net will send a letter to the Subscriber explaining its decision. Health Net will also notify UC. Kaiser Once form is received status of approved/disapprove d is mailed to subscriber and to UC. Western Health Advantage WHA communicates to UC if a covered dependent is deemed not eligible for disabled status. A notice is also sent to the member. Form Required 1. Overage Dependent Letter 2. Disabled Dependent Certification Form. The forms can be found on the Group Admin Site or Anthem/UC Microsite The top portion of the attached Disabled Dependent Certification (DDC) form needs to be completed & signed by the Subscriber and the bottom portion needs to be completed by the Disabled dependent's Physician and returned to the A&G/Membership Case Coordinator directly (fax number (818) ) Disabled Dependent Enrollment Application WHA Declaration of Disability form. 9