42 U.S.C. § 300gg–28: Coverage of dependent…

Summary

Health plans and insurance companies must keep a dependent student's health coverage if the student takes a medically needed leave from college because of a serious illness or injury. A medically needed leave means the break starts while the student is sick or hurt, a doctor says the leave is needed, and the leave causes the student to lose their active student status. Coverage cannot end until either 1 year after the first day of the leave or the date the coverage would normally stop under the plan — whichever comes first. The rule only applies to a dependent who was enrolled as a student right before the leave. The plan or insurer must get a written note from the student’s treating doctor saying the student has a serious illness or injury and the leave is medically necessary. When a plan asks for proof of student status, it must explain these continued-coverage rules in plain language. The dependent keeps the same benefits during the leave. If the family’s coverage changes to a different plan or insurer, the remaining leave time stays protected under the new coverage.

Title 42, §300gg–28

The Public Health and Welfare, 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 or individual health insurance coverage, a leave of absence of such child from a postsecondary educational institution (including an institution of higher education as defined in section 1002 of title 20), 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, or a health insurance issuer that offers group or individual health insurance coverage, shall not terminate coverage of such child under such plan or health insurance coverage 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 or health insurance coverage.

(2)Dependent child described

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

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

(B)was enrolled in the plan or coverage, 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 or individual health insurance coverage only if the plan or issuer of the coverage 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, and a health insurance issuer that offers group or individual health insurance coverage, shall include, with any notice regarding a requirement for certification of student status for coverage under the plan or coverage, 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 or individual health insurance coverage, 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

Codification Section was formerly classified to section 300gg–7 of this title prior to renumbering by Pub. L. 111–148.

Amendments

2010—Subsec. (a). Pub. L. 111–148, § 1563(c)(6)(A), formerly § 1562(c)(6)(A), as renumbered by Pub. L. 111–148, § 10107(b)(1), substituted “individual health insurance coverage” for “health insurance coverage offered in connection with such plan” in introductory provisions. Subsec. (b)(1). Pub. L. 111–148, § 1563(c)(6)(B)(i), formerly § 1562(c)(6)(B)(i), as renumbered by Pub. L. 111–148, § 10107(b)(1), substituted “or a health insurance issuer that offers group or individual health insurance coverage” for “or a health insurance issuer that provides health insurance coverage in connection with a group health plan” in introductory provisions. Subsec. (b)(2). Pub. L. 111–148, § 1563(c)(6)(B)(ii), formerly § 1562(c)(6)(B)(ii), as renumbered by Pub. L. 111–148, § 10107(b)(1), substituted “individual health insurance coverage” for “health insurance coverage offered in connection with the plan” in introductory provisions. Subsec. (b)(3). Pub. L. 111–148, § 1563(c)(6)(B)(iii), formerly § 1562(c)(6)(B)(iii), as renumbered by Pub. L. 111–148, § 10107(b)(1), substituted “individual health insurance coverage” for “health insurance coverage offered by an issuer in connection with such plan”. Subsec. (c). Pub. L. 111–148, § 1563(c)(6)(C), formerly § 1562(c)(6)(C), as renumbered by Pub. L. 111–148, § 10107(b)(1), substituted “health insurance issuer that offers group or individual health insurance coverage” for “health insurance issuer providing health insurance coverage in connection with a group health plan”. Subsec. (e)(1). Pub. L. 111–148, § 1563(c)(6)(D), formerly § 1562(c)(6)(D), as renumbered by Pub. L. 111–148, § 10107(b)(1), substituted “individual health insurance coverage” for “health insurance coverage offered in connection with such a plan”.

Statutory Notes and Related Subsidiaries

Effective Date

Section applicable with respect to plan years beginning on or after the date that is one year after Oct. 9, 2008, and to medically necessary leaves of absence beginning during such plan years, see section 2(d) of Pub. L. 110–381, set out as a note under section 9813 of Title 26, Internal Revenue Code.

§300gg–28 Coverage of Dependent Students on Medically Necessary Leave of Absence