Click here to skip navigation Home  |  Subject Index  |  Important Links  |  Contact Us  |  Help

U.S. Office of Personnel Management - Ensuring the Federal Government has an effective civilian workforce

Advanced Search

Insurance Services Programs

FEHB Handbook

Family Members
Page 2 of 3

page: Previous Page 1 2 3 Next Page


List of Medical Conditions that would Cause a Child to be Incapable of Self-Support During Adulthood

If your child has one of the following disabilities noted in the medical certificate, and the disability began before age 22, your employing office or health benefits carrier can automatically extend continued coverage.

  • AIDS - CDC classes A3, B3, C1, C2, and C3 (not seropositivity alone)
  • Advanced Muscular Dystrophy
  • Any malignancy with metastases or which is untreatable
  • Chronic Hepatic Failure
  • Chronic neurological disease, whatever the reason, with severe mental retardation or neurologic impairment, for example:
    • Cerebral Palsy
    • Ectodermal Dysplasia
    • Encephalopathies
    • Uncontrollable Seizure Disorder
  • Chronic Renal Failure
  • Inborn errors of Metabolism with complications such as the following:
    • Adrenoleukodystrophy
    • Gaucher disease
    • Glycogen storage diseases
    • Homocysteinuria
    • Lesch-Nyhan disease
    • Mucopolysacharide disease
    • Nieman-Pick disease
    • Phenylketonuria
    • Primary hyperoxaluria
    • Tay-Sachs disease
  • Mental Retardation with IQ of 70 or less
  • Osteogenesis Imperfecta
  • Severe acquired or congenital Heart Disease with decompensation which is not correctable
  • Severe Autism
  • Severe Juvenile Rheumatoid Arthritis
  • Severe Mental Illness requiring prolonged or repeated hospitalization
  • Severe Organic Mental Disorder
  • Xeroderma Pigmentosa

This list doesn't include all the disabilities that would cause a child to be incapable of self support.

Medical Certificate

Your child's doctor must complete a medical certificate for the employing office to make its determination of incapacity of self-support. The certificate must state that your child is incapable of self-support because of a physical or mental disability that existed before he/she became age 22 and that can be expected to continue for more than one year. In addition, the certificate must include the following information:

  • your child's name and birth date;
  • the type of disability;
  • the period of time the disability has existed and the date the impairment began;
  • diagnosis and history of the specific medical condition(s), references to findings from previous examinations, treatment and responses to treatment;
  • clinical findings from the most recent physical examination, including objective findings of physical examination, results of laboratory tests, x-rays, EKG's and other special evaluations or diagnostic procedures, and, in the case of psychiatric disease, the findings of mental status examinations and the results of psychological tests;
  • assessment of the current clinical status and plans for future treatment;
  • assessment of degree to which the medical condition has become static or stabilized and an explanation of the medical basis for the conclusion;
  • the probable future course and duration of the disability, including an estimate of the expected date of full or partial recovery;
  • the special supervisory, physical assistance, or custodial care requirements of your child;
  • any treatments, rehabilitation programs, educational training or occupational accommodation that would result in your child becoming self-supporting; and
  • the doctor's name, signature, office address and telephone number.

When to Submit Certificate

You may submit the medical certificate to your employing office when you first enroll or at any time in which your child is covered under your self and family enrollment, but no later than 60 days before your child reaches age 22.

If your employing office determines that your child is incapable of self-support, your employing office must notify the carrier of your plan by letter, before your child reaches age 22. The letter must identify you by name and social security number, and state the name and date of birth of your disabled child as well as the duration of the approval. It will send the letter to the carrier with a regular transmittal report. It will not send the medical evidence used in its determination to the carrier, but will attach it to your most recent Health Benefit Election form (SF 2809) or other enrollment request in your Official Personnel Folder.

If you have a new enrollment, your employing office will note its determination of incapacity of self-support in the Remarks section of your SF 2809.

Use of Physicians

In making its medical determinations, your employing office must use a physician's services if available, unless your child's condition is one for which it can automatically extend continued coverage. In doubtful cases, or if no physician is available, your employing office may request assistance from: Office of Personnel Management, Retirement and Insurance Service, Office of Insurance Programs, P.O. Box 436, Washington, D.C. 20044.

Duration and Approval of Incapacity for Self-Support

Depending on your child's medical certificate, your employing office may approve coverage due to disability for a limited period of time (1 year, for example), or without time limitation (permanent). Your employing office must also confirm that your child meets the financial dependency requirement.

Renewal of Medical Certificate

If your employing office approves your child's medical certificate for a limited period of time, it must remind you, at least 60 days before the date the certificate expires, to submit either a new certificate or a statement that the certificate will not be renewed. If it is renewed, your employing office must notify the carrier of your plan of the new expiration date by letter.

Failure to Renew Certificate

If you don't renew a medical certificate for a disabled child age 22 or over, your child's status as a family member automatically ends and he/she is no longer covered. Your employing office must notify you and the carrier of your plan that your child is no longer covered.

Late Certificates

If you submit a medical certificate for a child after a previous certificate has expired, or after your child reaches age 22, your employing office must determine whether the disability existed before age 22. If your employing office determines that it did, and you continuously had a self and family enrollment, your child is considered to have been a covered family member continuously since age 22.

page: Previous Page 1 2 3 Next Page

Handbook Contents