Medically Disabled Eligible Dependent Children

An eligible dependent that has never married and that is under the age of 23 years and that is enrolled as an eligible family member, and living in the employee's or annuitant's household, may continue to be enrolled after attaining age 23 if he/she is incapable of self support because of physical disability or mental incapacity and if he/she is dependent upon the eligible employee or annuitant for support and care. A disability certification is required to ensure disabled dependent children remain covered after the age of 23.

The disabled dependent may be continued under such coverage only under the following conditions:

1. The dependent was enrolled as a disabled child at the time of the employee's initial enrollment; or

2. The dependent became disabled while enrolled as an eligible family member prior to attaining age 23.

1. Dependents who are married, legally separated or divorced.

2. Dependent whose disability occurred after age 23.

3. Dependents over age 23 who were enrolled in, and later deleted from, any State-sponsored dental plan.

4. Dependents over age 23 who are not currently enrolled in any State-sponsored dental plan.

"Family Members" who are not eligible for coverage include, but are not limited to:

1. A stepchild for whom the employee or annuitant does not provide "parental supervision and substantial financial support" such as in the case of a step-child not living in the employee's or annuitant's household;

2. An otherwise eligible dependent who is on active duty, U.S. military service;

3. A dependent child who is eligible for a State-sponsored dental plan in his or her own right as a State employee must enroll in own State-sponsored plan (if deleted from parent’s State-sponsored plan, then offer COBRA);

4. A disabled child whose disability occurred after age 23;

5. A child over age 23 who was once certified as eligible and disabled but subsequently is unable to meet certification requirements for continued disability;

6. Parents, grandparents, common law, children under age 23 who marry and/or subsequently divorce, except for legal annulments, whether or not they live with the employee or annuitant; and

7. Other relatives or persons not identified as a legal spouse, certified domestic partner or eligible child.

1. A dependent child covered under a non State-sponsored dental plan;

2. A spouse not living in the employee's household (ie., moved out of household);

3. A certified domestic partner not living in the employee's household;

4. A child over age 18.

Employees on Their Parents Plan When Hired

When dependent children of State employees who are under the age of 23 become State employees, they are no longer considered dependent children. If these children are eligible to enroll in dental benefits in their own right as State employees, they must enroll and be deleted from their parent's State plan. If the dependent children do not qualify for State dental benefits as State employees they may remain on their parent's State-sponsored plan, provided they are under age 23.

When the parents delete these children from their State-sponsored dental plans, the children should be offered COBRA, regardless of the fact that the children may be eligible to enroll in their own right.

Dual/Split Dental Coverage

There is no dual coverage allowed. State employees may not have dual coverage. At the time a spouse or dependent enrolls as a State employee, coverage as a dependent on a spouse's or parent's State dental plan must be terminated on the effective date of the enrollment as an employee. There is no split coverage allowed. State employees may not split dependent coverage; all dependent children must be enrolled by one State employee. The department must correct these types of enrollments retroactive to the date they began and notify the employee accordingly. Use Permitting Event Code 42 (enrolled, but not eligible) on the STD. 692 and submit to SCO for corrective action. Employees will be responsible for dental expenses incurred during a period of ineligibility. Departments should ensure that new employee benefit orientation packages provide information regarding dual/split dental coverage.

Note: Employees (including unmarried employees) and/or dependents may not have dual or split coverage under any dental plan offered by the State of California and/or the California State University (CSU) system, including retirees.

Court Ordered Dental Coverage - Family Code Section 3760-3773 and 4726

A court order may be issued which could require a dental enrollment action. Each court order contains specific instructions for both the employer and the employee which must be followed. Orders of this type are generally subject to the program's eligibility rules.

In the event documentation is necessary to add a dependent child or children to an employee's dental plan, complete a STD. 692 using Permitting Event Code 16. The Permitting Event Date will be the date of the court order.

If a court order is issued and an employee has voluntarily deleted a spouse, the Personnel Office should reenroll the spouse until the divorce becomes final. When the divorce becomes final, the ex spouse must be mandatorily deleted from coverage and becomes eligible for COBRA. Use Permitting Event Codes 17a or 21a to reenroll. The Permitting Event Date will be the date of the court order.

When completing a STD. 692 resulting from a court order, indicate in the Remarks Section "Court Ordered". If an employee refuses to sign the enrollment form, the Personnel Office should indicate "Administrative Addition of Dependent Child or Spouse" in the employee signature block and submit to SCO for processing.

Court Ordered Dental Coverage - NATIONAL MEDICAL SUPPORT NOTICE - Notice to Withhold for Health Care Coverage

As noted previously, there may be a court order issued which will require a dental enrollment action. A support order known as a National Medical Support Notice (NMSN) is now being used more frequently by the courts to provide coverage for dependent children.

Each NMSN contains specific instructions for both the employer and the employee, which must be followed. Orders of this type are generally subject to the Dental Program's eligibility rules. However, the NMSNs are structured such that a personnel office may be required to administratively enroll an employee into a dental plan if the employee does not voluntarily enroll. NMSN orders are not contingent on whether employees decline or refuse to enroll themselves and their dependents into a dental plan.

The enrollment document (STD. 692) should be coded using enrollment code 01 (or code 04 for P.I. employees). Note in the remarks section: "Enrollment based on National Medical Support Notice". For P.I. employees, control period requirements for eligibility will still apply. For departments receiving a NMSN for an employee, who is currently enrolled in the FlexElect or CoBen Cash Option, the employee must continue the cash option enrollment unless the employee has experienced a permitting event (e.g., loss of other coverage) to allow cancellation.

The effective date of the enrollment will be the first of the following month after the order is received in the personnel office.

Note: Including children added to group coverage under a Qualified Medical Child Support Order (QMCSO). This is a judgment, decree, or order that requires that a child receive benefits under group coverage regardless of his/her status as a dependent of the covered employee.

Employees Currently Not Enrolled (Excluding Bargaining Units 5 and 6)

If the dependent(s) covered in the NMSN is within the State of California and able to see the same dental provider as the employee, and the employee is willing to make a voluntarily enrollment of him/herself and the dependent(s) to comply with the NMSN, the employee may choose a State-sponsored prepaid plan.

If any of the dependents covered in the NMSN are outside the State of California, and the employee is willing to voluntarily enroll the dependent(s), the employee only has the option of enrolling in either the Delta Premier dental plan or the Delta PPO dental plan.

If the personnel office must enroll the employee and dependent(s) administratively, the personnel office should enroll the employee and dependent(s) in the State-sponsored Delta Premier dental plan.

Employees Currently Enrolled (Excluding Bargaining Units 5 and 6)

If the employee is already enrolled in a prepaid dental plan, and the dependent(s) covered in the NMSN is within the State of California and able to see the same dental provider as the employee, the employee may add the NMSN covered dependent(s) to his/her current prepaid plan. If all NMSN covered dependents cannot seek services from the same prepaid plan provider or if the NMSN covered dependent(s) resides out-of-state, an employee making a voluntary enrollment of the NMSN dependent(s) may choose between the State-sponsored Delta Premier dental plan and the Delta PPO dental plan. If the personnel office must enroll the dependent(s) administratively and the dependent(s) is unable to see the same prepaid provider as the employee, the personnel office should change the employee's enrollment (now with dependents) into the State-sponsored Delta Premier dental plan.

When enrollment of dependents onto an employee's existing dental benefits occurs through the authority of a NMSN, and there is no need for the personnel office to administratively change employee's dental plan based on the coverage requirements created by the NMSN, the personnel office should use Permitting Event Code 16 (change of custody) to add the dependent(s).

Employees in Bargaining Unit 5 or 6

For employees in Bargaining Units (BU) 5 or 6, all the conditions stated above apply. For BU 5 employees enrolled in the CAHP Blue Cross dental plan, and BU 6 employees enrolled in one of the CCPOA benefit trust dental plans, the respective benefit trust must be notified of the NMSN, with a copy of the NMSN sent to the benefit trust administrator, along with a copy of the enrollment document (STD. 692).

Authority

For State and Local Plans, sections 401 (e) & (f) of the Child Support Performance and Incentive Act of 1998.