The Vermont Statutes Online

Title 8 : Banking and Insurance

Chapter 107 : Health Insurance

Subchapter 007 : CHILD AND DEPENDENT COVERAGE

• § 4057. Coverage of children

  (a) Definition. “Health insurance plan” has the same meaning as in section 4011 of this chapter and shall be subject to the same excepted benefits, in each case, as set forth in 45 C.F.R. § 146.145, as in effect as of December 31, 2017.

  (b) Newborn coverage.

  (1) A health insurance plan that provides dependent coverage of children shall also provide that health insurance benefits applicable to children are payable with respect to a newly born child of the insured or subscriber from the moment of birth. Coverage for a newly born child shall include coverage of injury, sickness, and necessary care and treatment of medically diagnosed congenital defect or birth abnormality.

  (2) Coverage for a newly born child shall be provided without notice or additional premium for not less than 60 days after the date of birth. If payment of a specific premium or subscription fee is required in order to have the coverage continue beyond such 60-day period, the policy may require that notification of the birth of the newly born child and payment of the required premium or fees be furnished to the health insurer within a period of not less than 60 days after the date of birth.

  (c) Adopted child coverage.

  (1) As used in this section:

  (A) “Child” means, in connection with any adoption or placement for adoption of the child, an individual who has not attained 18 years of age as of the date of the adoption or placement for adoption.

  (B) “Placement for adoption” means the assumption and retention by a person of a legal obligation for total or partial support of a child in anticipation of the adoption of the child. The child’s placement with a person terminates upon the termination of such legal obligations.

  (2) In any case in which a health insurance plan provides coverage for dependent children of covered individuals, the plan shall provide benefits to dependent children placed with covered individuals for adoption under the same terms and conditions as apply to the natural, dependent children of the covered individuals, irrespective of whether the adoption has become final.

  (3) A health insurance plan shall not restrict coverage under the plan of any dependent child adopted by a covered individual, or placed with a covered individual for adoption, solely on the basis of a preexisting condition of the child at the time that the child would otherwise become eligible for coverage under the plan, if the adoption or placement for adoption occurs while the covered individual is eligible for coverage under the plan.

  (d) Coverage required until 26 years of age. A health insurance plan that provides dependent coverage of children shall continue to make that coverage available for an adult child until the child attains 26 years of age, provided that this subsection shall not apply to a plan providing coverage for a specified disease or other limited benefit coverage, and further provided that nothing in this subsection shall require a plan to make coverage available for the child of a child receiving dependent coverage.

  (e) Coverage of adult child with a disability.

  (1) A health insurance plan that provides for terminating the coverage of a dependent child upon attainment of the limiting age for dependent children specified in the policy shall not limit or restrict coverage with respect to an unmarried child who meets all of the following criteria:

  (A) is incapable of self-sustaining employment by reason of a mental or physical disability that has been found to be a disability that qualifies or would qualify the child for benefits using the definitions, standards, and methodology in 20 C.F.R. Part 404, Subpart P;

  (B) became so incapable prior to attainment of the limiting age; and

  (C) is chiefly dependent upon the employee, member, subscriber, or policyholder for support and maintenance.

  (2) Coverage under subdivision (1) of this subsection shall not be denied any person based upon the existence of such a condition; provided, however, that a health insurance plan may require reasonable periodic proof of a continuing condition not more frequently than once every year.

  (f) Coverage of leave of absence from college. A health insurance plan that covers dependent children who are full-time college students beyond 18 years of age shall include coverage for a dependent’s medically necessary leave of absence from school for a period not to exceed 24 months or the date on which coverage would otherwise end pursuant to the terms and conditions of the policy or coverage, whichever comes first, except that coverage may continue under subsection (b) of this section as appropriate. To establish entitlement to coverage under this subsection, documentation and certification by the student’s treating health care professional of the medical necessity of a leave of absence shall be submitted to the health insurer or, for self-insured plans, the health plan administrator. The health insurance plan may require reasonable periodic proof from the student’s treating health care professional that the leave of absence continues to be medically necessary.

  (g) Parental rights. When a child has health coverage through the health insurer of a parent, the health insurer shall:

  (1) provide such information to either parent as may be necessary for the child to obtain benefits through that coverage;

  (2) permit either parent, a provider with parental authorization, the State Medicaid agency as assignee, or any State agency administering health benefits or a health benefit plan for which Medicaid is a source of funding to submit claims for covered services, and to appeal the denial of any benefit, without the approval of the other parent; and

  (3) make payments on claims submitted in accordance with subdivision (2) of this subsection directly to the parent who paid the provider, the provider as assignee, the State Medicaid agency, or any State agency administering health benefits or a health benefit plan for which Medicaid is a source of funding.

  (h) Child vaccine coverage. No health insurer shall reduce its coverage for pediatric vaccines below the coverage provided as of May 1, 1993. (Recodified and amended 2025, No. 11, § 2, eff. September 1, 2025.)