Can incapacitated children be covered beyond age 26?

Eligibility Requirements

To continue health insurance coverage for a dependent child beyond age 26 due to incapacitation:

1. The child must already be enrolled in the State Group Insurance Plan immediately before and on their 26^th birthday.
2. The incapacitation must have occurred before the child’s 26th birthday, and medical documentation and certification is required.
3. The child must be mentally or physically disabled and incapable of earning a living.
4. The application to continue coverage beyond age 26 must be submitted before the child’s 26^th birthday.

Step 1: Submit the Required Form

• Complete the Certificate for Incapacitation for Dependent Child Application.
• The form must be submitted before the child turns 26.
• The form includes:
  • A section completed by the employee.
  • A physician’s statement detailing the diagnosis, treatment, and prognosis.

Download the form here:  Incapacitated Dependent Application
Fax to: 615-741-8196
Or upload via Zendesk

Step 2: Review by Insurance Carrier

• The insurance carrier will determine eligibility based on the submitted documentation.
• If approved, periodic recertification may be required.
• If the child is later determined to no longer be disabled, coverage will end permanently and cannot be reinstated.

Grandfathered Clause for Agencies Joining the State Plan for the First Time

For Agencies Newly Joining the State Plan for the first time:

1. Incapacitated dependents who do not meet the current plan’s dependent definition may still be enrolled if they satisfy the requirements of the Plan Document grandfather provision. 
2. To be considered, the agency must provide:
   • A copy of the dependent definition from the previous insurance carrier.
   • Proof of coverage for the dependent in the month prior to the agency’s joining the State Group Insurance Plan for the first time.

Important Responsibility of the Head of Contract

• It is the head of contract’s responsibility to track the expiration date of the incapacitation certification.
• Neither Benefits Administration nor the insurance carrier will send reminders when coverage is about to end.