An employee’s Self and Family enrollment includes unmarried children over age 22 who are incapable of self–support because of physical or mental incapacity that existed before they reached age 22. A child over 22 years of age is classified as incapable of self–support only if (a) the incapacity can be expected to continue for at least 1 year (b) and the child is not capable, because of the disability, of working at a self–supporting job.
A disability such as total blindness or deafness is not in itself qualifying; although it may preclude employment in certain occupations, it does not preclude employment in all occupations or necessarily make a person incapable of self–support.
The onset of a disease before age 22 that does not result in incapacity for self–support until after age 22 does not bring a child within the definition of an eligible family member.
A child incapable of self–support because of mental or physical disability that existed before age 22 must be dependent upon the employee to qualify for health benefits coverage. In addition, a stepchild or foster child incapable of self–support as described above must also live with the employee in a regular parent–child relationship to qualify. The employing office is responsible for determining whether or not financial dependency has been established for health benefits purposes.
A child is automatically considered to be financially dependent upon the employee if the child is a legitimate child, an adopted child, a stepchild, a foster child, a recognized natural child who lives with the employee in a regular parent–child relationship, or a recognized natural child for whom a judicial determination of support has been obtained.
An employee who wishes to provide coverage for a recognized natural child who neither lives with the employee in a regular parent–child relationship nor is protected by a court determination of support submits proof of the recognized natural child’s dependency. Evidence that the employee makes regular and substantial contributions to the child’s support are accepted as proof of the child’s dependency. Examples of proof of dependency are:
- Evidence of eligibility as a dependent child under other state or federal programs.
- Proof of inclusion of the child as a dependent on the employee’s tax returns for previous years.
- Cancelled checks, money orders, or receipts for periodic payments received from the employee for, or on behalf of, the child.
- Evidence of goods or services that show regular and substantial contributions.
A Postal Service medical officer has authority to determine whether or not a child over age 22 is incapable of self–support because of mental or physical incapacity. The determination is based upon a medical certificate obtained by the employee at the employee’s own expense. The medical certificate is submitted to the Postal Service medical officer for a determination. All medical evidence is retained by the medical officer.
Submission requires the following:
- The medical certificate on which the medical officer makes the determination includes the following information:
- Name of child.
- Nature of disability.
- Period of time disability has existed.
- Probable future course and duration of disability.
- Doctor’s name and address.
- The medical certificate may be submitted to the medical officer at the time of initial enrollment or later. A medical certificate for a child who has been covered in a Self and Family enrollment is submitted at least 30 days before the child attains age 22.
The medical certificate for each individual case may be approved for a limited period of time, e.g., 1 year, or it may be approved without time limitation. The health benefits plan is advised of the duration of the approval in the letter to the health benefits plan (see 526.5).
If the medical certificate for a child is approved for a limited period of time, the employing office prepares a follow–up notice and reminds the employee, at least 30 days in advance of the date the certificate expires, to submit either a new certificate to the medical officer or a statement that the certificate will not be renewed. If it is renewed, the health benefits plan is notified of the new expiration date by letter in the same manner.
If the employee does not renew a certificate for an incapacitated child over age 22, the child’s status as a family member automatically stops. The child is no longer covered, and the employee is so notified.
If an employee submits a medical certificate for a child after a previous certificate has expired or after the child reaches age 22, the medical officer determines whether or not the incapacity existed before the child reached age 22. If it did, and the employee continuously had a Self and Family enrollment, the child is considered to have been family member and to have been covered continuously since age 22.
The employing office obtains the medical determination of the nearest Postal Service medical officer. This medical determination, as provided to the employing office, includes the length of approval of the incapacity (1 year, 2 years, permanent, etc.) The employing office then notifies the health benefits plan of the medical officer’s determination.
If it is determined that a child is incapable of self–support, the employing office notifies the health benefits plan (through the Eagan ASC) by letter, preferably shortly before the child reaches age 22. The letter identifies the employee by name and by Social Security number. The letter also states the name and the date of birth of the incapacitated child as well as the length of approval of the incapacity.
For a new enrollment, the medical officer’s determination of incapacity is entered in the Remarks section of the PostalEASE FEHB Worksheet.
The Eagan ASC submits a letter to the health benefits plan with SF 2811, Transmittal and Summary Report to Carrier.
