Dependent Certification Form - For Massachusetts Based Employer Groups (Page 2 of 2) in pdf

Dependent Certification Form - For Massachusetts Based Employer Groups Page 2

Massachusetts Law requires family policies (for fully insured plans) to include coverage for children up through the age of 25

(26th birthday) or for two years past the child’s loss of dependent status under the Internal Revenue Code, whichever occurs first.

Tufts Health Plan requires dependent age members to certify their dependent status, based on the guidelines set by the

Internal Revenue Service, in order to determine the appropriate dates of coverage. Recognizing that dependent status can

change, Tufts Health Plan will continue to request annual dependent status certification until the actual coverage termination

date is reached.

**On October 9, 2009, a new federal law went into effect (P.L. 110-381) that provides for a continuation of coverage for

those dependents that would otherwise lose eligibility because of a medically necessary leave of absence from a post

secondary educational institution or a change in enrollment from that institution.

The leave of absence must be medically necessary and must begin while the dependent is suffering from a serious illness or

injury and, the leave of absence would otherwise cause the dependent to lose coverage under the plan.

The dependent must have been enrolled in the group health plan prior to the first day of the leave or change in enrollment.

There must also be written certification by the dependent’s attending physician indicating that the dependent is suffering

from a serious illness or injury that necessitates the leave or change in enrollment status.

Coverage will be extended for up to one year or to the date on which coverage would otherwise terminate under the terms

of the plan, whichever comes first.

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Dependent Certification Form - For Massachusetts Based Employer Groups Page 2