August!10,!2010

The Honorable Timothy Geithner

Secretary

U.S. Department of the Treasury

1500 Pennsylvania Avenue, N.W.

Washington, D.C. 20220

The!Honorable!Kathleen!Sebelius

Secretary

U.S.!Department!of!Health!and!Human!Services

Washington,!DC!20201

The Honorable Hilda Solis

Secretary

U.S. Department of Labor

200 Constitution Avenue, N.W.

Washington, D.C. 20210

RE:!Comments!on!Interim!Final!Rules!Relating!to!Dependent!Coverage!of!Children!to!Age!26!(OCIIOL

4150LIFC)

Dear!Secretaries Geithner, Sebelius,!and!Solis:

We!appreciate!the!opportunity!to!comment!on!the!Interim!Final!Rule!released!May!13,!2010,

regarding!the!dependent!coverage!of!children!to!age!26!provisions!in!the!Patient!Protection!and!

Affordable!Care!Act!(ACA).

Georgetown!University’s!Center!for!Children!and!Families!(Georgetown!CCF)!is!an!independent,!

nonpartisan!policy!and!research!center!whose!mission!is!to!expand!and!improve!health!coverage!

for!America's!children!and!families.!Central!to!our!work!is!providing!research!and!policy!assistance!

to!state!administrators!and!stateLbased!organizations!on!strategies!for!covering!children!and!their!

families.!We!also!conduct!research!and!analysis!to!inform!federal!and!state!policymakers!about!

issues!impacting!children!and!families!in!health!care!reform!and!to!improve!Medicaid!and!CHIP,!

particularly!around!streamlining!enrollment!and!renewal!systems.!

With!young!adults!representing!28!percent!of!the!nation’s!uninsured!population,!Georgetown!CCF!

believes!that!the!dependent!coverage!rules!will!provide!an!important!new!option!for!families.!We!

were!particularly!pleased!that!the!Interim!Final!Rule!clarifies!that!health!plans!(for!new!plan!years!

on!or!after!September!23,!2010)!may!not!exclude!dependents!up!to!age!26!from!coverage!based!on!

their!tax!dependent!status,!residence!with!parents,!marital!status,!or!student!status.!In!addition,!we!

believe!that!the!Interim!Final!Rule!ensures!that!coverage!will!be!affordable!for!families!by!

prohibiting!variation!by!age!in!dependents’!premiums.
To!make!the!rules!most!responsive!to!the!needs!of!families,!we!ask!that!you!consider!the!following!

changes/additions!to!the!Final!Interim!Rule:

• Establish)an)inclusive)and)uniform definition)of)a)“dependent)child”. The!Interim!Final!

Rule!allows!plans!to!define!who!is!a!child!when!determining!which!child!can!be!covered.!As!a!

result,!plans!could!make!arbitrary!decisions!to!deny!dependent!coverage!to!adopted!children!or!

stepchildren.!Leaving!this!decision!to!the!discretion!of!insurers!would!be!inconsistent!with!the!

stated!goal!of!the!ACA’s!dependent!coverage!provision,!which!is!to!create!new!coverage!

pathways!for!uninsured!young!adults.!In!addition,!without!establishing!a!uniform!definition!

across!health!plans,!families!could!be!faced!with!conflicting!rules,!making!it!difficult!to!navigate!

the!options!available!to!them.!Last,!the!regulation would!be!counter!to!federal!tax!policy,!which!

expressly!defines!“child”!for!the!purposes!of!medical!expenses!to!include!both!stepchildren!and!

adopted!children.!We!urge!you!to!issue!revised!guidance!that!establishes!a!broad!definition!for!

a!dependent!child!to!include!a!biological!child,!a!stepchild,!and!an!adopted!or!foster!child

(including!formal!kinship!care!arrangements).!

• Clarify)that)a)young)adult)eligible)for)employer;sponsored)coverage)remains)eligible)

under)a)parent’s)plan)until)the)first)day)of)full)coverage.!Under!the!ACA,!until!2014,!

grandfathered!plans!are!not!required!to!cover!adult!dependents!up!to!age!26,!who!are!eligible!

to!enroll!in!their!own!employer!sponsored!insurance.!The!regulatory!language!does!not!address!

instances!in!which!a!young!adult!begins!a!new!job!but!is!required!to!wait!before!receiving!

benefits!due!to!an!established!waiting!period!or!a!preLexisting!condition!exclusion.!We!

encourage!you!to!clarify!that!a!young!adult!continues!to!be!eligible!for!the!dependent!coverage!

option!until!the!point!at!which!they!are!able!to!receive!full!benefits!under!their!employerL

sponsored!coverage.

• Develop)stronger)outreach,)monitoring)and)enforcement)strategies. Georgetown!CCF!

supports!the!requirement!that!beneficiaries!receive!“prominent!notice”!about!the!new!

dependent!coverage!rule.!However,!since!this!notice!is!directed!at!the!parent,!we!encourage!you!

to!develop!initiatives!that!would!utilize!university!networks!and!social!media to!educate!young!

adults!on!the!new!requirement.!We!also!urge!HHS!and!DOL!to!closely!review!ways!to!ensure!

successful!monitoring!and!enforcement!of!the dependent!coverage!extension.!Current!

insurance!monitoring!and!enforcement!rules!are!largely!reliant!on!states,!in!addition!to!

consumers identifying!and!reporting!concerns!or!issues.!However,!with!the!number!of!changes!

that!insurers!will!be!required!to!make!under!the!ACA!(including!the!new!dependent!coverage!

provisions),!the!federal!government!has!a!critical!regulatory!role!to!play!in!monitoring!and!

enforcing!plan!compliance.!We!also!encourage!you!to!work!with!state!insurance!commissioners!

or!regulators!to!ensure!they!have!the!resources!required!to!regulate!the!ACA!provisions,!and!

that!consumers!can!easily!obtain!assistance!when!faced!with!nonLcompliance!issues.

We!appreciate!your!consideration!of!our!comments.!Please!contact!us!at!dch28@georgetown.edu or!

202L687L7651!if!you!have!any!additional!questions.

Sincerely,

Dawn Horner

Dawn!Horner

Senior!Program!Director