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Requesting Adult Child Disability Approval
OverviewThis document outlines the process for requesting the review of the disabled status for an adult child by the health provider. If disability status is approved, the adult dependent may be added to the employee’s state group health, dental and/or vision benefit plans.
- Applications are required for all of the insurances the employee is requesting to have the adult child reinstated to. This includes health, dental and vision.
- The health provider, once contacted by ETF, will initiate the disability review process by mailing the disability packet to the employee.
- The employee is responsible for responding to the health provider and providing all necessary documentation as requested. The employee must provide a copy of the decision letter to the Benefit Administrator.
- The health provider will make the final determination in the disability status.
- Annually the health plan will contact the employee to re-certify the disability status.
- The UWSC will annually audit the Disability status in HRS.
- If the employee submits an application for removal of the disabled child from their coverage, the Benefit Administrator must uncheck the Disabled field and update the Relationship to Adult Child in HRS > Benefits > Employee/Dependent Information > Update Dependent/Beneficiary screen. If the employee elects to add the disabled child to their coverage in the future, they will have to go through the disability certification process.
Review of the Adult Child Disability Process:
Once an employee’s adult child is no longer considered their dependent for benefit purposes, the child is removed from the employee’s health, dental and vision benefit plans at the end of the month they turn age 26.
The employee may request review of the disabled status by the health provider to determine if the adult child qualifies as having a disability of long standing duration, are unmarried, dependent on the employee or the other parent for at least 50% of support and maintenance and are incapable of self-support.
The application must be submitted within 30 days of the health provider's approval. Preferred process will have the employee submitting the application(s) requesting the adult child to be reinstated based on disability approval. The submission of the applications will start the disability approval process with the health provider. Do not make enrollment entry into HRS at this time. Upon receipt of approval from the health provider, the applications will be entered into HRS.
If the employee worked directly with the health provider and received approval before submitting the application, simply have the employee provide you a copy of the approval letter from the health provider with the applications and enter in HRS based on the effective date of the approval.
Per Chapter 5 of the State Agency Health Insurance Administration Manual, the disabled dependent’s (child age 26 or older) coverage is effective the date the health plan approves the dependent’s disabled status. The employee submits an application which ETF forwards to the health plan to have them complete their disability review process. When the health plan has reviewed the adult child’s disability status, ETF will update the coverage accordingly. Documentation to support the disability is required as outlined in the Group Health Insurance Application/Change Form.
The below link provides a visual workflow for the Adult Child Eligibility through Disability process.
Actions Required by UWSS – Benefits Team
- UWSS upon receipt of health application from the institution, we will fax to ETF.
- Create ticket
- ETF will notify plan provider to forward disability packet to employee.
- Once the dependent has been removed from the MyETF system. The UWSS will enter the disability application into MyETF. The transaction will sit in Pending status.
- Upon receipt of the disability status decision from the health provider, ETF will NOT forward decision to UWSS via email.
- If approved, ETF will approve pending transaction in MyETF system.
- If denied, ETF will deny pending transaction in MyETF system.
- The employee must forward the approval letter to their institution.
- Upon receipt of decision letter from institution, UWSS pulls pending health application, attach the notice, and if approved verifies that the institution makes HRS entries and files.
- Close ticket
Actions Required by Institution Benefit Administrator
NOTE: If the employee is wanting to enroll the adult child (over age 26) as disabled in only the dental and/or vision plans, there will be no review by the health provider. We are allowing the employee to self- identify that adult child as disabled. They employee will need to provide a letter signed by the medical provider. The letter should indicate that the unmarried adult child is incapable of self-support because of mental or physical disability that can be expected to be of long-continued or indefinite duration of at least one year. This letter should be included with the applications. The adult child must still meet the requirement of being dependent on the employee or the other parent for at least 50% of support and maintenance and incapable of self- support. Please keep in mind if there is no health provider review, the adult child may not be added to the employee's health plan.
- Upon receipt of the health provider’s disability status decision the BA will:
- If denied, pull the pending applications, attach notice and file in the Employee Benefit folder.
- If approved, pull pending applications and process in HRS. Send copy of decision to UWSS.
- The BA updates the HRS > Benefits > Employee/Dependent Information > Update Dependents/Beneficiary > Personal Profile tab by changing the field, Relationship to Employee to “Child Tax Dependent”. Also check the box next to “Disabled” and enter the effective date (this is the approval date by the health provider).
- The BA updates the HRS > Benefits > Enroll In Benefits > Health Benefits enrollment screens by creating an ADM event adding the "child tax dependent" using Enrollment Code "Add", and Enrollment Reason "Disabled Dependent Over Age 26".
- Change the coverage level as necessary.
- Review Retroactive Deductions if created.
- State Agency Health Insurance Administration Manual Chapter 5 — Changing Coverage: https://etf.wi.gov/publications/et1118/direct
- Child Loses Dependent Status Due to Age chart: https://www.wisconsin.edu/ohrwd/admin/download/ben/events/child-dep-status.pdf *
- Dependent eligibility guidelines. Additional information can be found at: https://www.wisconsin.edu/ohrwd/benefits/famchng/child-loss-dep-status/ *
- Note: Each plan has its own dependent eligibility guidelines. Additional information can be found at: https://www.wisconsin.edu/ohrwd/benefits/famchng/child-loss-dep-status/ (If you are unable to access this site, contact your Security Administrator.)