August 6, 2010 

The Honorable Kathleen Sebelius, Secretary 

U.S. Department of Health and Human Services 

Hubert H. Humphrey Building 

200 Independence Avenue, SW 

Washington, DC 20201 

RE: File Code OCIIO-4150-IFC 

Dear Secretary Sebelius: 

On behalf of Family Voices, Inc., I would like to submit the following comments on the Interim 

Final Rules (IFR) pertaining to dependent coverage of children to age 26 under the Patient 

Protection and Affordable Care Act (ACA). 

Family Voices is a national nonprofit organization of families whose children have special health 

care needs, such as disabilities or chronic illnesses, and the professionals who serve them. The 

organization’s mission is to achieve family-centered care for all children and youth with special 

health care needs and/or disabilities. Through Family Voices’ national network, the organization 

provides families with tools needed to make informed decisions, advocates for improved public 

and private policies, builds partnerships among professionals and families, and serves as a 

trusted resource on health care. 

Family Voices is particularly interested in the issue of dependent coverage until age 26 because it 

is currently very difficult for young adults with special health care needs to obtain insurance after 

aging out their parents’ plans, due to pre-existing condition exclusions. Moreover, young adults 

with special health care needs may have more trouble than their healthier peers in either 

attending school full-time, thereby qualifying for their parents’ coverage, or in finding and/or 

maintaining jobs that offer insurance coverage. 

In general, we are very pleased with the IFR the Department has issued to implement the ACA’s 

extension of parental insurance coverage to children up to age 26. However, we have several 

suggestions about how the regulations might be improved. 

Definition of Dependent. First, we urge that you define dependent to include adopted children, 

stepchildren, former foster children, children who had a legal guardian, grandchildren (in cases 

where insured grandparents serve or served as the actual or legal guardians of their 

grandchildren), and other adult children who would be covered by the insured’s plan if the child 

were a minor, student, or other dependent otherwise permitted to be on a parent’s plan. Defining 

dependent to include these individuals would be consistent with the intent of the law to simply 

extend the age through which dependents can remain on the plans they were on before “aging 

out.” 
Loss of employer-sponsored or other insurance. We recommend that the final regulations 

clarify that an adult child can enroll or re-enroll in a parent’s insurance plan without having to 

wait for an open enrollment period if the child should lose his/her own employer-sponsored 

insurance or other insurance coverage. 

Our other suggestions are related to the fact that, until 2014, the law allows a “grandfathered” 

group plan to exclude from coverage dependents who are “eligible to enroll” in their own 

employer-sponsored plans. Clarifications with respect to this provision could help to avoid 

situations where young adults would be uninsured or underinsured because they are neither in a 

meaningful employer-sponsored plan nor permitted to be enrolled in their parent’s grandfathered 

plan. 

Delayed employer-sponsored coverage. For individuals with special health care needs, it is 

particularly important to be insured at all times. Therefore, we urge that the final rule clarify that 

a dependent may enroll in or remain on his/her parent’s insurance plan during any waiting period 

that might be imposed under the dependent’s employer benefits package or employer-sponsored 

insurance plan. 

Inadequate employer-sponsored coverage. For individuals with special health care needs, it is 

particularly important that insurance coverage be continuous and comprehensive. Accordingly, 

we recommend that the final rule allow a dependent to enroll in his/her parents’ grandfathered 

plan if the employer-sponsored plan in which the dependent is “eligible to enroll” is a plan 

offering only limited or temporary benefits, such as an accident-only or “mini-med” plan. 

Similarly, the final rule should prohibit grandfathered plans from denying dependent coverage if 

the dependent’s employer-sponsored insurance imposes any pre-existing condition exclusions. 

Finally, we recommend that the final rule should allow dependents to enroll in or remain on their 

parents’ grandfathered plans if the dependent is offered only an employer-sponsored plan that 

has received a waiver from annual cap limitations. 

Thank you for your attention to these comments. If you should need additional information, 

please feel free to contact one of our Public Policy Co-Directors, Janis Guerney 

(jguerney@familyvoices.org, or 202-546-0558) or Brooke Lehmann 

(blehmann@familyvoices.org or 202-333-2770). 

Sincerely, 

Sophie Arao-Nguyen, Ph.D. 

Executive Director