FEHB and disabled dependents is a topic not usually encountered in the administration of federal employee benefits. Recently, we assisted a client in obtaining Federal healthcare benefits for a disabled dependent over the age of 26. It appears this issue is more prevalent with existing federal employees already enrolled in an FEHB plan when a disabled child (incapable of self support) turns age 26 rather than a new employee enrolling in FEHB for the first time whose disabled child is already over the age of 26. This client was otherwise unaware of the ability to maintain his dependent on his federal employee healthcare benefits and assumed ineligibility when the federal employee healthcare plan (GEHA) dropped the dependent at age 26.
General FEHB Eligibility
The Office of Personnel Management (OPM) provides that as a Federal employee, you are eligible to elect FEHB coverage, unless your position is excluded by law or regulation. Even then, there are numerous special provisions for people in part-time or intermittent employment, temporary appointments, and specifically named positions. Further, in the context of this article, under current law, if your plan covers children (i.e. self and family), you can now add or keep your children on your health insurance policy until they turn 26 years old. Children can join or remain on a parent’s plan even if they are Married.
Role of Your Local Human Resources Office
Local federal agency Human Resource offices bear primary responsibility for administering federal employee access to all benefits, including healthcare. In most cases, agencies will have a dedicated human resources benefits section (“benefits specialists”). The administration of benefits includes the initial election of benefits at new employee orientation, subsequent changes due to open season or qualifying life events, corrections to errors in enrollment, and verification of all qualifications and criteria to access benefits. A benefits specialist should always be your primary point of contact concerning all benefits. In some instances, you may need to bypass Human Resources if they are unresponsive or provide you wrong information, which often happens.
Final Decision Making Authority for Enrollment Eligibility
Your employing office (Human Resources) is responsible for making decisions as to whether a family member is eligible for coverage in any regard, disabled or otherwise. If the carrier of your health benefits plan has any questions concerning an eligible family member, it will ask you or your employing office for more information. The health plan carrier must accept the final decision of your Human Resources office on your family member’s eligibility. This includes the question of FEHB and Disabled Dependents. However, keep in mind, presenting false information concerning eligibility constitutes fraud and if discovered, will assuredly result in your employment termination and possibly criminal charges. We always recommend full transparency and disclosure.
FEHB and Disabled Dependent Basic Thresholds for Coverage
To even consider whether your disabled child can be covered under your federal employee healthcare benefits, you must first be enrolled in “self and family” or “self plus one” category of your health benefits plan.
Relationship to FEHB Enrollee
Family members eligible for coverage under a federal employee’s Self and Family enrollment are his or her spouse (including a valid common law marriage) and children under age 26, including legally adopted children, recognized natural (born out of wedlock) children and stepchildren. A child is eligible for coverage under Self and Family enrollment, if a state-issued birth certificate lists the employee as a parent of that child. A grandchild is not an eligible family member, unless the child qualifies as the legal foster child of the employee.
Disabled Dependent Eligibility
A child age 26 or over who is incapable of self support because of a mental or physical disability that existed before age 26 is an eligible family member for the purpose of FEHB eligibility. Your employing office (human resources) will be responsible for evaluating the child’s relationship to you as the enrollee and disabled dependents status to determine whether the child is a covered family member. The decision of that office will be final and binding upon the healthcare plan carrier.
Disabled Dependent Criteria
The FEHB Handbook provides that a child age 26 or over who is incapable of self-support because of a disability that existed before age 26 may be eligible for coverage under your FEHB enrollment. This physical or mental disability must be expected to continue for at least one year and, because of the disability, the dependent is not capable of working at a self-supporting job. A disability such as blindness or deafness isn’t qualifying in itself because it doesn’t necessarily make someone incapable of self-support. The onset of a disease before age 26 that doesn’t result in incapability for self-support until age 26 or after doesn’t qualify a child for continued coverage as a family member. These are important nuances to understand.
Your dependent child is generally incapable of self-support when:
- he/she is certified by a state or federal rehabilitation agency as unemployable;
- he/she is receiving: (a) benefits from Social Security as a disabled child; (b) survivor benefits from CSRS or FERS as a disabled child; or (c) benefits from OWCP as a disabled child;
- a medical certificate documents that: (a) your child is confined to an institution because of impairment due to a medical condition; (b) your child requires total supervisory, physical assistance, or custodial care; or (c) treatment, rehabilitation, educational training or occupational accommodation has not and will not result in a self-supporting individual;
- a medical certificate describes a disability that appears on the list of medical conditions; or
- you submit acceptable documentation that the medical condition is not compatible with employment, that there is a medical reason to restrict your child from working, or that he/she may suffer injury or harm by working.
Medical Certificate for Disabled Dependents
Your child’s (dependent) doctor must complete a medical certificate for the employing office to make its determination of incapacity of self-support. The certificate must state that your child is incapable of self-support because of a physical or mental disability that existed before he/she became age 26 and that can be expected to continue for more than one year. If you are new enrollee, your employing office will note its determination of incapacity of self-support in the remarks section of form SF 2809.
As with any consultation concerning any aspect of federal employment or benefits, there are unique nuances, facts, and circumstances that may affect the application of the information provided. Employees should contact their local Human Resources office if they have any concerns and seek appropriate consultation if they believe they are receiving incorrect information, guidance, or decisions from that office.
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