August 6, 2010 

Jim Mayhew 

Office of Consumer Information and Insurance Oversight 

Department of Health and Human Services 

Hubert H. Humphrey Building, Room 445-G 

200 Independence Avenue, SW. 

Washington, DC 20201 

Attention: OCIIO– 4150–IFC 

 

Dear Mr. Mayhew: 

The American Academy of Pediatrics (AAP) and the Society for Adolescent Health and 

Medicine (SAHM) appreciate this opportunity to submit comments regarding the interim final 

rules for Group Health Plans and Health Insurance Issuers Relating to Dependent Coverage of 

Children to Age 26 (45 CFR Parts 144, 146, and 147, 26 CFR Parts 54 and 602, 29 CFR Part 

2590). AAP is a non-profit professional organization of 60,000 primary care pediatricians, 

pediatric medical sub-specialists, and pediatric surgical specialists dedicated to the health, 

safety, and well-being of infants, children, adolescents, and young adults. SAHM is a multidisciplinary organization of health professionals committed to advancing the health and wellbeing of adolescents and young adults through education, research, clinical services, and 

advocacy. 

We applaud much of the regulation, but note that there are certain individuals (those who are 

stepchildren, adopted children or receiving kinship care) who may have been inadvertently 

excluded. Additionally, some of the uncertainty surrounding coverage for young adults from 

their employers and otherwise could be better defined. We recommend that notice of the new 

benefit for covering young adults be more prominent, and therefore more effective. Finally, 

enforcement authority for these provisions appears to be missing from the regulation. The 

Academy and SAHM would urge that enforcement must be available for the provisions in the 

regulation to reform the status quo. 

Thank you very much for your attention to the views of the American Academy of Pediatrics 

and the Society for Adolescent Health and Medicine.

Sincerely, 

Judith S. Palfrey, MD, FAAP Lawrence J. D’Angelo, MD, MPH 

President President 

American Academy of Pediatrics Society for Adolescent Health and Medicine 

JSP/LJD/rh 

SOCIETY FOR ADOLESCENT 

HEALTH AND MEDICINE 
Dependent Coverage of Children to Age 26 (45 CFR Parts 144, 146, and 147, 26 CFR 

Parts 54 and 602, 29 CFR Part 2590)

The American Academy of Pediatrics (the Academy) is dedicated to the health of all children. 

The Academy has also adopted Principles and issued policy statements that call for insurance 

coverage for all. The Academy’s Access Principles state, “Quality health insurance should be 

a right, regardless of income, for every child, pregnant women, their families, and ultimately 

all individuals.”1 In addition, the Academy’s Principles of Child Health Financing state, “All 

children and pregnant women have a right to comprehensive health care that is fully portable 

and ensures continuous coverage.”2 

The Society for Adolescent Health and Medicine (SAHM) is strongly committed to the health 

and well-being of all adolescents and young adults. In 2009 SAHM adopted a set of principles 

for health care reform.3 These principles strongly support health insurance coverage for all 

adolescents and young adults. 

Based on these positions, the Academy and SAHM are strongly in support of many of the 

aspects of the Interim Final Rules for Group Health Plans and Health Insurance Issuers 

Relating to Dependent Coverage of Children to Age 26 (the Age 26 Regulation). In 

particular, the Age 26 Regulation has a broad definition of dependent. This definition will 

allow young adults to join their parents’ plan without regard to their residency status, their 

financial dependence, or whether they attend school. This definition furthers the clear 

intention of the Affordable Care Act to increase health coverage by ensuring that a large 

number of previously uninsured young adults can obtain insurance. Moreover, the prohibition 

on varying dependents’ premiums with age is consistent with the law’s other provisions 

limiting discrimination in the health insurance market. This policy makes it clear that its 

intent is to cover young adults in an affordable way. 

Based on the intent of the Affordable Care Act and policy supported by the Academy and 

SAHM, the Academy and SAHM would urge modifications to the Age 26 Regulation to 

specifically include stepchildren, adopted children, and kinship care. If these groups are not 

included, many young people will be left out of the benefits of the Age 26 Regulation. A 

2004 survey identified an estimated 5.5 million stepchildren in the United States in 2004, as 

well as an estimated 1.5 million adopted children. There are strong policy reasons for their 

specific inclusion, including the fact that Sec. 152 of the US Tax Code explicitly includes 

step/adopted children in the definition of dependent and that ERISA prohibits discrimination 

against adopted children for dependent coverage. Additionally, as grandparents often have 

private coverage wrapping their Medicare coverage, including coverage for grandchildren to 

age 26 in what those plans may be required to cover should help reach the growing population 

of children care for by grandparents. 

Additionally, the Academy and SAHM would urge the Departments to clarify some of the 

contours of the regulation for young adults with Employer Sponsored Insurance. For instance, 

 

1

 See http://www.aap.org/advocacy/washing/mainpage.htm. 

2

 See http://aappolicy.aappublications.org/cgi/reprint/pediatrics;112/4/997.pdf. 

3

See A. English et al. Health Care Reform and Adolescents—An Agenda for the Lifespan: A Position Paper of 

the Society for Adolescent Medicine. J Adolesc Health 2009; 45:310–315 
it is unclear whether grandfathered parent plans must consider so-called “mini-med” or 

catastrophic coverage as qualifying insurance. These plans are frequently purchased by young 

adults due to cost constraints. The Academy and SAHM would urge the Department to err on 

the side of enacting access to insurance with more than minimal coverage for the young adult 

population, and thus allow some flexibility in qualifying insurance based on whether 

insurance packages for young adults include the Essential Benefits outlined in the Affordable 

Care Act. If they do not, we would respectfully suggest that they should not be considered 

insurance capable of disqualifying the young adult from enrolling in their parents’ plans. 

Additionally, the Academy and SAHM would urge that young adults with waiting periods for 

enrollment in their employers’ insurance should be granted the option of remaining on the 

plans of their parents. This could be accomplished by defining “eligible to enroll” in the 

child’s employer’s plan to exclude the waiting period common in plans available to young 

adults. The Academy and SAHM would also urge the Departments to address whether young 

adults with employer plans containing pre-existing condition exclusions are eligible for 

coverage by their parents’ plans. If this is not done, a young adult may be “eligible to enroll” 

in employer coverage but be denied insurance coverage. The Departments should set forth 

rules that if an employer denies coverage for a young adult, that young adult should have 

access to his or her parents’ insurance plan. Additionally, the Academy and SAHM would 

urge the Departments to allow for open enrollment periods for young adults who lose their 

jobs. We urge you to consider a policy solution for gaps in coverage for young adults losing 

employer coverage who may exhaust COBRA benefits. Perhaps a loss of coverage by the 

young adult could lead to a specific open enrollment period or a qualifying life event for 

coverage to accrue on the parents’ insurance. Overall, the Academy and SAHM would urge 

the Departments to provide employers with clear guidelines regarding whether a young adult 

has real access to insurance. 

The Academy and SAHM also urge the Departments to make the Notice of the new benefit of 

coverage for young adults effective. Mailed documents can get lost or ignored, and we would 

urge that insurers be required to conduct multiple levels of outreach to explain the new benefit 

to families. Additionally, the Academy and SAHM would urge the Departments to consider 

whether the Notice could constitute an add-on to notices required by COBRA in the case of an 

individual leaving employment. We would also urge the Departments to track the 

effectiveness of the Notice by looking to how many families actually take up the option to 

extend coverage to their young adults. In this oversight, it should be noted that some transient 

populations may be less connected to written notice and internet fact sheets. We would 

further urge that outreach and education campaigns reach college campuses, leading 

consumer/parents groups like the AARP, and would suggest that transitional guidance 

counselors in colleges and human resources departments be made aware of the new law. 

Finally, the Academy and SAHM would urge that you give strong consideration to the 

enforcement of the Age 26 Regulation. As with the grandfather regulation, the notice to 

families outlined in the interim final rule is a good first step, but it relies heavily on 

individuals to monitor the practices of their employers and insurers. We encourage the 

Departments to work closely with states to develop monitoring and enforcement mechanisms 

to verify effective implementation of the Age 26 Regulation.