PRIA, Government Policy, Made Personal

Summary

Health plans must keep a dependent student's coverage if the student takes a medically necessary leave from a college or other postsecondary school. A medically necessary leave means the leave started while the child had a serious illness or injury, the leave is needed for medical reasons, and the leave causes the student to lose student status for plan coverage. The plan cannot end the child’s coverage because of that leave before the earlier of the date 1 year after the first day of the leave or the date the coverage would have ended anyway. To get this protection, the plan must have a written note from the child’s treating doctor saying the child has a serious illness or injury and needs the leave, and the child must have been enrolled as a student under the plan right before the leave. When a plan asks for proof of student status, it must include an easy-to-understand description of these rules. The child must keep the same benefits they had as a student during the leave. If the parent’s or plan’s coverage changes (for example, a new insurer or a switch to self-insurance), these rules still apply for the rest of the medically necessary leave.

Title 26, §9813

Internal Revenue Code, Source: USLM XML via OLRC

(a)Medically necessary leave of absence

In this section, the term “medically necessary leave of absence” means, with respect to a dependent child described in subsection (b)(2) in connection with a group health plan, a leave of absence of such child from a postsecondary educational institution (including an institution of higher education as defined in section 102 of the Higher Education Act of 1965), or any other change in enrollment of such child at such an institution, that—

(1)commences while such child is suffering from a serious illness or injury;

(2)is medically necessary; and

(3)causes such child to lose student status for purposes of coverage under the terms of the plan or coverage.

(b)Requirement to continue coverage

(1)In general

In the case of a dependent child described in paragraph (2), a group health plan shall not terminate coverage of such child under such plan due to a medically necessary leave of absence before the date that is the earlier of— (A)

(B)the date on which such coverage would otherwise terminate under the terms of the plan.

(2)Dependent child described

A dependent child described in this paragraph is, with respect to a group health plan, a beneficiary under the plan who—

(A)is a dependent child, under the terms of the plan, of a participant or beneficiary under the plan; and

(B)was enrolled in the plan, on the basis of being a student at a postsecondary educational institution (as described in subsection (a)), immediately before the first day of the medically necessary leave of absence involved.

(3)Certification by physician

Paragraph (1) shall apply to a group health plan only if the plan, or the issuer of health insurance coverage offered in connection with the plan, has received written certification by a treating physician of the dependent child which states that the child is suffering from a serious illness or injury and that the leave of absence (or other change of enrollment) described in subsection (a) is medically necessary.

(c)Notice

A group health plan shall include, with any notice regarding a requirement for certification of student status for coverage under the plan, a description of the terms of this section for continued coverage during medically necessary leaves of absence. Such description shall be in language which is understandable to the typical plan participant.

(d)No change in benefits

A dependent child whose benefits are continued under this section shall be entitled to the same benefits as if (during the medically necessary leave of absence) the child continued to be a covered student at the institution of higher education and was not on a medically necessary leave of absence.

(e)Continued application in case of changed coverage

If—

(1)a dependent child of a participant or beneficiary is in a period of coverage under a group health plan, pursuant to a medically necessary leave of absence of the child described in subsection (b);

(2)the manner in which the participant or beneficiary is covered under the plan changes, whether through a change in health insurance coverage or health insurance issuer, a change between health insurance coverage and self-insured coverage, or otherwise; and

(3)the coverage as so changed continues to provide coverage of beneficiaries as dependent children,

this section shall apply to coverage of the child under the changed coverage for the remainder of the period of the medically necessary leave of absence of the dependent child under the plan in the same manner as it would have applied if the changed coverage had been the previous coverage.

Notes & Related Subsidiaries

Editorial Notes

References in Text

section 102 of the Higher Education Act of 1965, referred to in subsec. (a), is classified to section 1002 of Title 20, Education.

Statutory Notes and Related Subsidiaries

Effective Date

Pub. L. 110–381, § 2(d), Oct. 9, 2008, 122 Stat. 4086, provided that: “The

Amendments

made by this Act [enacting this section, section 1185c of Title 29, Labor, and section 300gg–7 and 300gg–54 of Title 42, The Public Health and Welfare] shall apply with respect to plan years beginning on or after the date that is one year after the date of the enactment of this Act [Oct. 9, 2008] and to medically necessary leaves of absence beginning during such plan years.”

§9813 Coverage of Dependent Students on Medically Necessary Leave of Absence