CurrentMedical Mutual - OhioPolicy N/A

Request to Extend Limiting Age for Dependent Child

Form and policy guidance for requesting continuation of dependent coverage past the limiting age for mentally or physically disabled dependents; affects policyholders and attending physicians covered by Medical Mutual (Ohio).

Policy Summary

PayerMedical Mutual - Ohio

PolicyRequest to Extend Limiting Age for Dependent Child

Policy CodePolicy N/A

Change TypeAdministrative — no material changes

Effective DateN/A

Next Review DateN/A

Key ActionComplete Section 1 by the policyholder and Section 2 by the attending physician and return to the Membership Department to request extension of dependent coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

31proof timeframe (days)

5physical impairment classes

5intellectual impairment levels

1return address entries

Eligibility for Continued Dependent Coverage

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ALL of the following

Dependent is not married.
Disability began before the certificate's limiting age for dependent children.
Dependent is incapable of self-sustaining employment due to mental or physical disability which commenced prior to the limiting age for dependent children specified in the certificate.
Dependent is primarily dependent upon the policyholder for support and maintenance.
Policyholder must furnish proof of incapacity and dependency within thirty-one days of the dependent's attainment of the limiting age for dependent children specified in the certificate.
Policyholder must complete Section 1 and the attending physician must complete Section 2 of the form, providing clinical details (date of onset, diagnosis, symptoms, objective findings, nature of treatment) to substantiate Disabled Dependent Status as defined by the certificate or law.

'Disabled Dependent Status' means the incapacity to achieve self-support through employment at a minimum level because of any condition defined by contract or law as handicap.

Codes and Impairment Classifications

Referenced form return addressmixed

Please return form to Attn: Membership Department Medical Mutual 100 American Road Cleveland, OH 44144

Impairment classification thresholds — physical and intellectual levels

Physical impairment classesClass 1: No limitation (capable of heavy physical activity; 0-10%); Class 2: Slight limitation (capable of light manual activity; 15-30%); Class 3: Moderate limitation (capable of clerical/administrative sedentary activity; 35-55%); Class 4: Marked limitation (50-70%); Class 5: Severe limitation (incapable of minimal sedentary activity; 75-100%).

Intellectual impairment categories (IQ ranges)None: IQ 85 and above; Borderline: IQ 71-84; Mild: IQ 50-70; Moderate: IQ 35-49; Severe/Profound: IQ 34 and below.

Use of impairmentsAttending physician selects the applicable physical class and/or intellectual category on the physician report to document level of functional capacity and support eligibility determination.

Submission, Timelines, and Warnings for Requesting Extension

Documentation Required

Submission requirements for extension request — Sections 1 & 2

To the Policyholder: Your certificate (or benefit booklet) provides that coverage for certain Dependents may continue beyond the limiting age specified in your Schedule of Benefits. The Policyholder must complete each question in Section 1, and the Dependent's Attending Physician must complete each question in Section 2. Please return the completed application to Medical Mutual, Attention: Membership Department, 100 American Road, Cleveland, OH 44144.

Policyholder must complete Section 1 in full.
Attending physician must complete Section 2 in full.
Return completed application to Medical Mutual, Membership Department, 100 American Road, Cleveland, OH 44144.

Prior Authorization

Proof timeframe

Proof of the dependent's incapacity and dependency must be furnished to Medical Mutual within 31 days of the dependent attaining the limiting age for dependent children as specified in the certificate. Furnish all requested medical documentation and evidence of dependency promptly to avoid denial or termination of coverage.

Deadline: within 31 days after dependent reaches limiting age.
Provide medical evidence of incapacity (physician-completed Section 2, diagnosis, symptoms, objective findings, treatment).
Provide documentation of dependency (tax, guardianship, SSI/Medicare if applicable).

Denial Risk

Fraud warning

Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Key Definitions

Definition of 'Disabled Dependent Status' and related meaning

Definition'Disabled Dependent Status' means the incapacity to achieve self-support through employment at a minimum level because of any condition defined by contract or law as handicap.

Key eligibility elementsMust be not married; disability began before the certificate's limiting age; incapable of self-sustaining employment due to the disability which commenced prior to limiting age; primarily dependent on the policyholder for support and maintenance.

Evidence sourceAttending physician completes Section 2 of the report providing diagnosis, date of onset, continuous incapacity status, objective findings and treatment details to support Disabled Dependent Status.