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Requesting Adult Child Disability Approval

Overview

This 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.

Process Considerations:

  • 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.
  • UWSS 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.

You may click on the links below to navigate directly to a section:

Process Flow 
The below link provides a visual workflow for the Adult Child Eligibility through Disability process.

DisabilityAge26ProcessMap.pdf


Actions Required by the Institution and UW-Shared Services for State Group Health

  1. Benefits Administrator will collect completed application from employee and submit to UWSS.
    1. Do not enter application into HRS.
  2. Upon receipt of SGH application, UWSS will submit application to ETF for approval.
    1. Verify that SGH enrollment is not entered into HRS.
  3. ETF will send notification of the disabled dependent status to the health plan.
  4. The health plan will send approval paperwork to the dependent’s provider.
  5. The provider will complete the approval paperwork and submit to the health plan.
  6. The health plan will review the completed paperwork and approve or deny the disabled dependent status.
    1. The approval letter will be mailed to the employee. 
  7. The employee submits a copy of the approval letter to the Benefit Administrator.
  8. The Benefit Administrator forwards a copy to UWSS.
    1. If approved, UWSS will submit the approval to ETF to update the SGH contract and will update HRS.
    2. If denied, the ETF disabled dependent status will be cancelled. 
    3. File into the employee’s Benefit Folder.

Actions Required by the Institution and UW-Shared Services for Dental/Vision

  1. Benefits Administrator will collect completed dental/vision application(s) from employee and complete enrollment into HRS.
    1. If participating in Benefits Data Management, submit completed application(s) to UWSS for processing.
  2. Upon entry of dental/vision application(s) into HRS, the next file will notify the vendor of the disabled dependent.
  3. The vendor will provide a form to the employee if the disabled dependent was not reported as previously stated as disabled or the dependent becomes permanently disabled after the initial enrollment.
  4. Employee will complete form as necessary and submit back to the vendor.
  5. No further action is required.
    1. If denied, the vendor will notify ETF and ETF will notify UWSS.

Additional Resources

Related KBs:

Related Links:




Keywords:Age 26 adult dependents adult child disability disability approval adult child eligibility disability status process for institutional responsibilities BN, Benefits BN, Benefits   Doc ID:20246
Owner:Christina S.Group:UW–Shared Services
Created:2011-09-13 12:08 CDTUpdated:2021-10-13 13:15 CDT
Sites:UW–Shared Services
CleanURL:https://kb.uwss.wisconsin.edu/adult-child-disability-process
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