Laserfiche embed: Disabled Dependent Initial Review and Recertification Form
Disabled Dependent Initial Review and Recertification Form
A dependent child can be covered by the State Health Benefit Plan (SHBP) until he/she turns age 26 years old. If your dependent child is currently covered by SHBP and was disabled prior to their 26th birthday, he/she may be eligible to continue coverage after their 26th birthday if you can provide proof of the child’s disability. You must submit either: 1) the Initial Review Form or 2) the Recertification Form below, as applicable.
Initial Review Form: Only submit this form if SHBP has never made a determination that your dependent child is disabled, and they are currently covered by SHBP.
Recertification Form: Only submit this form if SHBP has previously notified you that your dependent child's status is “temporarily disabled” or “permanently disabled” and they are currently covered by SHBP.
Submission Deadline: Your Initial Review Form or Recertification Form must be submitted no later than 31 days after the dependent child’s coverage termination date (e.g., if the dependent child turns age 26 on August 1, the last day of coverage is August 31, and the last day to submit the Initial Review Form or Recertification Form is October 1).
After Submitting Your Initial Review Form or Recertification Form: You will receive an automated acknowledgment email. If your Initial Review Form or Recertification Form is approved, SHBP will email you the Dependent Continued Coverage Physical or Mental Disability attending a Physician or Psychologist Questionnaire, which must be completed by your child’s physician and/or psychologist.
Review Timeframe: The review process generally takes up to 60 days after you submit your Dependent Continued Coverage Physical or Mental Disability Attending a Physician or Psychologist Questionnaire.
Denials: If your request to continue coverage for your child as a disabled dependent is denied and you disagree with the denial, you must submit your request for a Tier 2 Formal Appeal within 30 days of the denial by visiting: Tier 2 Formal Appeal Request Form.