Civil Service Federal Employees Federal Employees Federal Employees

Retirement Group Life Health Benefits Retirement

System Insurance Program System

United States

Office of Personnel Management

Retirement and Insurance Service

Benefits Administration Letter

Number: 97-206 Date: August 15, 1997 

Subject: Federal Employees Health Benefits (FEHB) Program: Continued Coverage

for Disabled Children Over Age 22

A. Background On July 18, 1997, the Office of Personnel Management (OPM)

published final FEHB regulations in the Federal Register

(62 FR 38433) concerning Opportunities to Enroll and Change

Enrollment. These regulations, which take effect on August 18,

1997, include a provision that authorizes FEHB carriers to

approve continued coverage for disabled children over age 22

under certain conditions.

 

B. Current regulations Under FEHB law, a child's coverage ends at age 22 unless the

 current FEHB regulations, only the employing office may

child is determined incapable of self-support because of a

physical or mental disability that existed before age 22. Under

determine incapacity. (The retirement system is the employing

office for annuitants.) Consequently, enrollees who contact their

insurance carrier to request continued coverage for a disabled

child are referred to their employing office.

 

C. Reason for change There are certain medical conditions that are so severe that there

 would be no question that they would not abate and that they

would cause children to be incapable of self-support during

adulthood. We believe that if an enrollee whose child has one of

these conditions should contact the carrier instead of the

employing office, the carrier should be able to extend coverage

without referring the enrollee to the agency. 

To assure that enrollees in this situation have uninterrupted

coverage for their disabled children, we have revised our current

regulations to permit either the employing office or the carrier to
make determinations of incapacity when the child's

medicalcondition appears on a list prepared by OPM.

 

D. New Procedures Attached is an updated list of medical conditions that would cause

children to be incapable of self-support. If an enrollee contacts

his or her insurance carrier instead of the employing office for

approval of continued coverage for a child over age 22, and the

child's condition began before age 22 and appears on this list, the

carrier may approve continued coverage for the child. If the

child's condition does not appear on the list, the carrier will refer

the enrollee to his or her employing office. The employing office

then follows its usual procedures in making determinations of

incapacity.

Note: The procedures that agencies must follow to make a selfsupport determination are located in Subchapter S12 of the FEHB

Handbook for Personnel and Payroll Offices. The attached list

replaces the one in the March, 1989 edition.

 

E. Notification When employing offices determine incapacity, they must

continue to communicate their determinations to the carrier in the

same manner as they have always done. However, now that

carriers are also authorized to make determinations in certain

cases, the employing office needs documentation that the

enrollee's child over age 22 has been determined incapable of

self-support.

This is to alert you that we are instructing FEHB insurance

carriers that if they approve continued coverage for an enrollee's

child over age 22, they send the notice of approval to the enrollee

and advise the enrollee to give a copy of the notice to his or her

employing office. Therefore, some of your employees may soon

begin providing you with notices from their FEHB carriers

approving continued coverage for their disabled children over age

22. If you receive such a notice from an enrollee, please include

it with the enrollee's FEHB enrollment documentation.

If you have any questions about this regulatory change, please

contact Barbara Myers of my staff at (202) 606-0004, or

BMYERS @ OPM.gov.

 

Abby L. Block, Chief

Insurance Policy and 

 Information Division

Attachment 
LIST OF MEDICAL CONDITIONS THAT WOULD CAUSE CHILDREN TO BE 

INCAPABLE OF SELF-SUPPORT DURING ADULTHOOD

AIDS - Center for Disease Control classes A3, B3, C1, C2, and C3. (not seropositivity alone)

Any malignancy with metastases or which is untreatable.

Inborn Errors of Metabolism with complications such as the following:

Phenylketonuria

Homocysteinuria

Primary hyperoxaluria

Adrenoleukodystrophy

Tay-Sachs disease

Nieman-Pick disease

Gaucher disease

Glycogen storage diseases

Mucopolysaccharide disease

Lesch-Nyhan disease

Xeroderma Pigmentosa

Ectodermal Dysplasia

Chronic neurological disease, whatever the reason, with severe mental retardation or

neurologic impairment, for example:

Encephalopathies

Cerebral Palsy

Uncontrollable Seizure Disorder

Severe acquired or congenital Heart Disease with decompensation which is not correctable

Severe Mental Illness requiring prolonged or repeated hospitalization

Severe Juvenile Rheumatoid Arthritis

Osteogenesis Imperfecta

Chronic Hepatic Failure

Chronic Renal Failure

Severe Autism

Severe Organic Mental Disorder

Mental Retardation with IQ of 70 or less

Advanced Muscular Dystrophy