Q. If I have group coverage though my employer, does the insurer have to cover my adult child if she is eligible (not married, no dependents, resident of PA or full-time college student, and not enrolled in or entitled to benefits from a government program)?

 

A. No, the insurer has to offer the coverage to your employer, but your employer has the discretion whether to include the adult child coverage in the group policy. 

 

Q. May an employer choose to offer Act 4 coverage only to those adult children enrolled in college?

 

A. No. In the past, some insurers made available policies that offered coverage to children over age 18 only if the child was enrolled full-time in college. Now, insurers must make available policies that offer coverage to children up through age 29 if the child is not married, has no dependents, is a resident of the Commonwealth or a full-time college student, and is not provided coverage through another policy or a government health care benefits program. The purpose of Act 4 is to expand coverage to adult children who do not have other coverage, so under Act 4, an insurer may not prevent the employer from having the option of covering adult children, so long as the child is not married, has no dependents, and is not provided coverage through another policy or a government health care benefits program. The employer may not further restrict the coverage to only full-time college students or only residents of the Commonwealth.

 

Q. If someone is not currently enrolled in adultBasic, would eligibility for adultBasic make them ineligible for Act 4 coverage?

 

A. No. the “government health care benefits program” criteria is limited to persons “enrolled in or entitled to benefits under any government health care benefits program.” Since the adultBasic program is not an entitlement program, only those actually enrolled in adultBasic would be precluded from coverage under Act 4. 

 

Q. If a child covered by a current policy that covers full-time college students graduates from college in December of 2009 and the policy does not renew until July of 2010, does this child go off the health insurance for those 6 months and then put back on in July of 2010? Does the answer change if the child graduates from college in May 2010 (after Act 4 takes effect), and the policy does not renew until September 2010? 

 

A. A child who graduates either before or after Act 4 takes effect, but before his or her current policy is renewed, would go off of the insurance until the renewal. If the employer then opts to include adult children on the policy, and the child meets all of the criteria, then the child could again be covered by the policy. Alternatively, the insurer and employer may choose to expand the policy’s current coverage by means of a rider or endorsement to cover the interim period for all students in this type of situation.

 

Q. If a child with a pre-existing conditions loses coverage because she ages out, and then becomes eligible several months later (i.e., more than 63 days later) for the coverage again at the time the policy renews, may the insurer impose a pre-existing condition exclusion? 

 

A. A child eligible for coverage under Act 4 may enroll at open enrollment without a pre-existing condition exclusion -- but only at open enrollment.

 

Q. Must the adult child be unemployed or can he have a job that doesn’t carry insurance?

 

A. There is no requirement that the adult child be unemployed.  The adult child may have a job that does not provide health insurance, as long as he or she meets the other criteria.

 

Q. If I get coverage for my adult child under my employer’s group coverage, who is responsible for the cost?

 

A. The employee is responsible for the cost of the coverage. 

 

Q. Does Act 4 apply to insurers that are based outside of Pennsylvania?

 

A. Act 4 applies to insurers who issue, deliver, execute or renew group health insurance policies in PA.  If the insurer is out of state, but issues a policy to an in-state employer, then the policy is issued in PA.

 

Q. Will the Insurance Department create enrollment forms and member notices for the adult child coverage law?

 

A. The Insurance Department does not plan to create enrollment forms and member notices.