Fillable Disability Status Request Form - Emblem Health (Page 2 of 2) in pdf

Your completed paperwork is required within 31 days of your dependent reaching the terminating age. Completed

paperwork includes this form and a physician’s summary.

The PhYsIcIAN’s suMMARY must be on the physician’s office stationery and signed by your dependent’s doctor.

It must include:

• The specific nature of the condition

• Signs and symptoms associated with the condition

• The date such condition commenced; and

• A recent evaluation (within six months) that demonstrates how your dependent’s condition prevents any form of

self-sustaining employment and that accommodation is not possible

• Physician’s contact information including telephone and fax numbers – PRINTED CLEARLY.

FOR NEW ENROLLMENTs ONLY: The subscriber must provide evidence that the dependent has had continuous

health plan coverage, group or individual, prior to attaining the limiting age and the coverage remains in effect.

You must attach a certificate of creditable coverage or evidence of prior coverage with this request.

According to New York State Insurance Law, continued coverage for your dependent may be available, if he or she:

• Is not married

• Suffers from mental illness

, mental retardation

, developmental disability

or physical handicap

• Had such a condition before reaching the age at which dependent coverage would otherwise end

• I s not capable of self-sustaining employment* due to the condition, and proof of this is sent to us within 31 days

of reaching the coverage termination age.

1. Mental Illness: This term refers to a mental disease or mental condition that is manifested by a disorder or disturbance in behavior, feeling,

thinking, or judgment to such an extent that the person afflicted requires care, treatment and rehabilitation. It does not include alcoholism,

substance abuse and chemical dependence.

2. Mental Retardation: This term refers to subaverage intellectual functioning that originates during the developmental period and is associated

with impairment in adaptive behavior.

3. Developmental Disability: This term refers to a disability of a person that:

a. ( 1) I s attributable to mental retardation, cerebral palsy, epilepsy, neurological impairment, familial dysautonomia or autism;

(2) Is attributable to any condition of a person found to be closely related to mental retardation because such condition results in similar

impairment of general intellectual functioning or adaptive behavior to that of a mentally retarded person or requires treatment and

services similar to those required for such person; or

(3) Is attributable to dyslexia resulting from a disability described in subparagraph (1) or (2) of this paragraph

b. Originates before such person attains age 22;

c. Has continued or can be expected to continue indefinitely; and

d. Constitutes a substantial handicap to such person’s ability to function normally in society.

4. Physical handicap: This term refers to a condition, function or physical disability that makes participation in certain usual activities of daily

living difficult or impossible. A physical handicap may be present at birth or develop over an individual’s lifespan.

* Th e inability to find employment or a reduction in work capability is not, in itself, evidence of eligibility. If a mentally retarded, mentally ill, developmentally

disabled, or physically handicapped dependent is working, the extent of his or her earning capacity will be evaluated. He/she must be chiefly dependent upon the

subscriber for support and maintenance.

This process relates only to determinations of eligibility for health coverage beyond the normal limiting age for a dependent child who is incapable of self-sustaining

employment due to mental illness, developmental disability, mental retardation or a physical handicap. A finding by EmblemHealth that the dependent child qualifies

as a dependent incapable of self-sustaining employment pursuant to the submission of a Disability Status Request Form does not mean that the dependent

is considered disabled by EmblemHealth for any other purpose.

Disability Status Request Form - Emblem Health Page 2

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