CurrentDenver-Health-Medical-PlanPolicy N/A

Statement of Dependent Eligibility Beyond Limiting Age Due to Developmental Disability or Mental/Physical Handicap

This document governs the process and required documentation for determining continuation of dependent coverage beyond the plan's limiting age when a dependent is developmentally disabled or has a mental or physical handicap; it affects subscribers, dependents, treating clinicians, and Denver Health Medical Plan (DHMP) adjudicators.

Policy Summary

PayerDenver-Health-Medical-Plan

PolicyDependent eligibility continuation for developmentally disabled or mentally/physically handicapped dependents

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionTreating physician or CRNP must complete and sign the attestation confirming incapacity, provide date condition began, diagnosis, and supporting reports.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4form sections (subscriber, dependent, clinician, DHMP use)

multiplebinary items for incapacity and residency

requiredclinical confirmation and signature

Continuation of Dependent Coverage Criteria

Continuation criteria and process

Policy Summary

PayerDenver-Health-Medical-Plan

PolicyDependent eligibility continuation for developmentally disabled or mentally/physically handicapped dependents

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionTreating physician or CRNP must complete and sign the attestation confirming incapacity, provide date condition began, diagnosis, and supporting reports.

SourceLink

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Subscriber completes and signs the subscriber and dependent sections: full dependent demographics, Social Security number, current address, relationship to subscriber, date of birth, employer information or date last employed, estimated monthly income of dependent, and percent of support supplied by subscriber; answers regarding permanent residence in the subscriber’s household and whether dependent was listed on the subscriber’s last Federal Personal Income Tax Return; provides explanations where indicated.

Treating Physician/Surgeon/CRNP completes the clinical attestation: indicates whether the dependent is developmentally disabled, has a physical handicap, a mental handicap, or other cause for incapacity; provides date the dependent became incapable of self-sustaining employment, diagnosis (and degree of disability if developmental), and attaches relevant reports (surgery, x-rays, ECGs or other special tests); answers employment capability questions and signs and dates the form.

DHMP adjudication recorded on the form: DHMP indicates whether dependent eligibility will continue (with effective month/day/year) or is declined and provides reason; Product Line Manager signs and dates the determination.

Clinical Attestation and Required Signatures

Documentation Required

Complete physician attestation and sign/date

Physician/Surgeon/CRNP must complete the attestation section on the form, answering all questions about whether the dependent is developmentally disabled, has a physical or mental handicap, or other condition; provide date the dependent became incapable of self‑sustaining employment, diagnosis (and degree of disability if developmental), relevant test/surgery reports, current functional status, employment capability, and sign and date the form. Any fee for completion is paid by the subscriber; omitted information will cause delays.

Check Yes/No for Developmentally Disabled, Physical Handicap, Mental Handicap, and Other and provide explanation if Other.
Provide date dependent became incapable of self‑sustaining employment and detailed diagnosis; include degree of disability if developmental and attach reports (surgery, x‑rays, ECGs, special tests).
Answer employment questions (has a job, job duties, ability to do full/part‑time work, will be capable of self support) and current confinement status (ambulatory, bed‑confined, house‑confined, hospital‑confined).
Print name, address, phone, sign and date the attestation.
Note: any fee for form completion is paid by the subscriber; omitted information will cause delays.

Key Definitions and Eligibility Questions

Conditions determining incapacity for self-sustaining employment

Developmentally DisabledPhysician must indicate Yes or No if the dependent is developmentally disabled and provide degree of disability if present.

Physical HandicapPhysician must indicate Yes or No if the dependent has a physical handicap.

Mental HandicapPhysician must indicate Yes or No if the dependent has a mental handicap.

Other conditionsPhysician must indicate Yes or No for any other condition and provide explanation when applicable.

Residency and tax dependency questions

Permanent residence in subscriber's householdForm asks whether the dependent permanently resides in the subscriber's household (Yes/No) and requires explanation if No.

Listed on last Federal Personal Income Tax ReturnForm asks whether the dependent was listed as a dependent on the subscriber's last Federal Personal Income Tax Return (Yes/No) and requires explanation if No.

Explanations required for negative responsesSpace is provided for explanations when residency or tax dependency questions are answered No.

OpenPayer

Statement of Dependent Eligibility Beyond Limiting Age Due to Developmental Disability or Mental/Physical Handicap

Continuation of Dependent Coverage Criteria

Billing and Support / Income Disclosure

Clinical Attestation and Required Signatures

Key Definitions and Eligibility Questions