Extending Health Plan Coverage for Disabled Dependents Beyond Age 26

Under the Affordable Care Act (“ACA”), most employer-sponsored health plans provide coverage for dependent children up to age 26. But what happens when your child has a disability? Can their coverage continue past age 26? The answer depends on the facts and circumstances.

When Can Coverage Continue?

Health coverage for a disabled child can extend beyond age 26 if certain criteria are met:

• The Dependent Must Be Disabled or Incapacitated: To qualify, the child must have a disability significant enough that it prevents them from independently earning a living or fully caring for themselves. The impairment typically needs certification from a licensed physician.
• Financial Dependence on the Employee: The dependent must primarily rely on the employee (parent or guardian) for financial support, including living expenses and ongoing care.
• Onset of Disability Before Age 26: Coverage continuation generally requires that the disability or incapacity was present before the child reached age 26. Disabilities occurring after age 26 usually do not qualify.

Documentation

Employers and insurance providers commonly request documentation to substantiate eligibility:

• Physician statements or medical certifications confirming permanent disability or incapacity.
• Proof of financial dependency, like tax documents or affidavits.

Additionally, employers and insurers typically require regular recertification to verify the ongoing disability and dependency.

Employers or the insurer will typically offer guidance and forms necessary to facilitate these processes. It is important for employees to stay informed of documentation requirements and deadlines, as missing a verification period could jeopardize ongoing coverage.

State Laws and Employer Flexibility

Although the ACA does not require employers to extend dependent coverage past age 26, many state insurance regulations mandate insurers and fully insured plans to do so for disabled dependents. Self-funded plans, regulated under ERISA, are exempt from state mandates but often voluntarily offer this extended coverage. Employees should always confirm availability and specifics of coverage past age 26 by consulting with their employer, insurer, or reviewing the plan documentation.

Recommendations for Employees

• Review your health plan’s specific rules regarding extended dependent coverage well before your child’s 26th birthday.
• Communicate proactively with your employer or plan administrator and submit required paperwork promptly.
• Be prepared to periodically confirm your child’s disability and dependency status as requested by your insurer.

Understanding these requirements and preparing documentation early helps ensure continuous and uninterrupted health coverage for your disabled adult dependent beyond age 26.