Topics Map > Human Resource System (HRS) > Benefits Administration
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.
- 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.
The below link provides a visual workflow for the Adult Child Eligibility through Disability process.
Actions Required by the Institution and UW-Shared Services
- Benefits Administrator will collect completed application from employee and submit to UWSS.
- Do not enter application into HRS.
- Upon receipt of SGH application, UWSS will submit application to ETF for approval.
- Verify that SGH enrollment is not entered into HRS.
- ETF will send notification of the disabled dependent status to the health plan.
- The health plan will send approval paperwork to the dependent’s provider.
- The provider will complete the approval paperwork and submit to the health plan.
- The health plan will review the completed paperwork and approve or deny the disabled dependent status.
- The approval letter will be mailed to the employee.
- The employee submits a copy of the approval letter to the Benefit Administrator.
- The Benefit Administrator forwards a copy to UWSS.
- If approved, UWSS will submit the approval to ETF to update the SGH contract and will update HRS.
- If denied, the ETF disabled dependent status will be cancelled.
- File into the employee’s Benefit Folder.
NOTE: If the employee is wanting to enroll the adult child (over age 26) as disabled in only 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.
Additional ResourcesRelated KBs:
- 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.)