Incapacitated dependent coverage will be granted to unmarried dependent children, regardless of age, who are incapable of self-sustaining employment by reason of physical handicap, mental illness, developmental disability, or intellectual disability and who became so incapable prior to attainment of the age at which dependent coverage would otherwise terminate.
Incapacitated dependent status is determined based upon the member's contract language, certification of the dependent’s condition by the treating physician/therapist and the medical criteria stated in Disability Evaluation under Social Security (Blue Book), published by the Social Security Administration, as a guide.
Regarding behavioral and behavioral health issues:
- Mental illness is defined as an affliction with a mental disease or mental condition which is manifested by a disorder or disturbance in behavior, feeling, thinking, or judgment to such an extent that the person afflicted requires care, treatment and rehabilitation.
- Intellectual disability is defined as subaverage intellectual functioning that originates during the development period and is associated with impairment in adaptive behavior.
- According to the American Psychiatric Association, subaverage intellectual functioning is defined as:
- An Intelligence Quotient (IQ) of 70 or below on individually administered IQ tests;
- Concurrent deficits or impairments in present adaptive functioning (i.e., the person’s effectiveness in meeting the standards expected for his or her age by his or her cultural group) in at least two of the following areas: communication, self-care, home living, social/interpersonal skills, use of community resources, self-direction, functional academic skills, work, leisure, health and safety); and
- The onset is before age 18 years.
- Developmental disability is defined as a disability of a person that:
- Intellectual disability, cerebral palsy, epilepsy, neurologic impairment or autism;
- Any other condition of a person found to be closely related to an intellectual disability because such condition results in behavior that is similar to that of a cognitively impaired person or requires treatment and services similar to those required for such person; or
- Has continued or can be expected to continue indefinitely; and
- Constitutes a substantial incapacitation to such person’s ability to function normally in society.
Under federal regulations of the Patient Protection and Affordable Care Act, all contracts, regardless of products and funding arrangements, are required to provide coverage for adult children until the adult child’s 26th birthday for plan years beginning after September 23, 2010.
Coverage for an incapacitated dependent child (adult or minor) will be determined by the Health Plan Medical Director based upon the certification of the dependent child’s condition by the treating physician/therapist and this policy.
Certification by the dependent child’s treating physician/therapist consists of submission of a completed Coverage Incapacitated Dependent Verification Form. Determination of an incapacited dependent child status may include the review of the dependent’s medical records and/or discussion with the requesting physician/therapist.
- Refer to the member’s subscriber contract for specific contract limitations. (Refer to the Description section for information regarding the Patient Protection and Affordable Care Act.)
- In order to be considered for coverage as an incapacitated dependent, the incapacitating condition must have existed prior to attainment of the age when dependent coverage would otherwise terminate (prior to contract dependent age limitations) and coverge must be a continuation of existing coverage.
- In order for a covered dependent to continue coverage beyond the date coverage would otherwise terminate due to age, the individual must currently have an incapacitating condition and be chiefly dependent upon the subscriber for support and maintenance. The subscriber must request continued coverage within 31 days from the date the dependent attains the termination age and submit a Coverage Incapacitated Dependent Verification Form as proof of the dependent's incapacity. Applications for coverage must be filed within 31 days of the incapacitated dependent's twenty-sixth (26th) birthday. Applications submitted after that timeframe will not be considered.
- Requests for incapacitated dependent status based upon physical, developmental disability or intellectual disability will be reviewed by the Health Plan Medical Director's appointed designee. Denials for incapacitated dependent coverage based upon physical, developmental disability or intellectual disability will be made by the Health Plan Medical Director.
- Requests for incapacitated dependent status based upon mental illness will be reviewed by the Health Plan Medical Director's appointed designee. Denials for handicapped dependent coverage based upon mental illness will be made by the Health Plan Medical Director.
- The subscriber and the dependent’s attending physician must complete Coverage Incapacitated Dependent Verification Form and submit it to the Health Plan for review.
- Appeal requests for previously denied incapacitated dependent status will be reviewed by the Medical Director’s appointed designee. If the additional information is not sufficient for approval, the services will be reviewed by the Medical Director.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders. DSM-5. Fifth edition. 2013. Washington, D.C.
- *Social Security Administration Office of Disability. Disability evaluation under Social Security. SSA Pub 64-039. 2008 Sep, last reviewed or modified 5/18/15 https://www.socialsecurity.gov/disability/professionals/bluebook/ accessed 5/11/16.
This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.
"Current Procedural Terminology © American Medical Association. All Rights Reserved"
History From 2018 Forward
Annual review, no change to policy intent.
Annual review, no change to policy intent.