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Qualified Medical Child Support Order Form. This is a Illinois form and can be use in Lake Local County.
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Tags: Qualified Medical Child Support Order, 174-CSR217, Illinois Local County, Lake
IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT
LAKE COUNTY, ILLINOIS
IN RE THE MARRIAGE OF
and
)
)
)
Petitioner, )
)
)
)
Respondent. )
Gen. No.:
QUALIFIED MEDICAL CHILD SUPPORT ORDER
,
This Order creates and recognizes the right of
, an employee
a child of
who is eligible to participate in the
of
group health plan described herein, to receive health benefit plan coverage under such group health plan.
This Order is intended to constitute a Qualified Medical Child Support Order (QMCSO) under section 609(a)
of the Employee Retirement Income Security Act of 1974, as amended (ERISA), and is entered pursuant
to the authority granted to the Court in 750 ILCS 505.2 of the applicable domestic relations laws of the
State of Illinois.
FINDINGS
1. PARTICIPANT:
The name, address, Social Security Number, and date of birth of the participant are as follows:
Name:
Address:
SSN:
DOB:
2. ALTERNATE RECIPIENTS:
The name, address, Social Security Numbers, and dates of birth of the participant’s child is as follows:
Name:
Address:
SSN:
DOB:
3. ALTERNATE RECIPIENTS’ REPRESENTATIVE:
The name and address of the custodial parent or representative is as follows:
Name:
Address:
NOW THEREFORE, IT IS HEREBY ORDERED AS FOLLOWS:
1. The Plan to which this Order applies is the Plan the participant is currently participating in.
2. The Plan is hereby ordered to provide the following coverage under the Plan: medical coverage, dental
coverage and vision care coverage.
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3. The Order applies to health coverage as provided to the participant by the Plan, which is a group
health plan (as defined in Section 607[1] of ERISA). In accordance with the requirements of the Plan and
ERISA, the Plan is hereby ordered to cover the participant and to cover the alternate recipients as
dependents under the medical plan choice for which the participant and the alternate recipients are
eligible. If the alternate recipients are not eligible for coverage under the participant’s current coverage,
the participant has 60 days to elect coverage available for both the participant and alternate recipients. If
no election is made within the 60 days, the participant and alternate recipients will be enrolled in the
Plan’s default coverage. The participant will pay all additional employee contributions associated with the
coverage of the alternate recipients, if applicable.
4. The coverage described in paragraph two shall begin upon the date the Order is qualified by the
Medical Plan Administrator and shall continue from such date until the earlier to occur of:
a. The date that the participant or alternate recipients would otherwise cease to be eligible for
coverage under the Plan in the absence of this Order, or
b. Date:
(mmddyyyy)
5. The participant is hereby ordered to secure and maintain the coverage specified in this Order during
the period described in this Order. The alternate recipients’ rights to continued health benefits shall
remain subject at all times to the payment of any applicable premiums, regardless of the method of
payment.
6. If the participant and the alternate recipients, or any of them, cease to be eligible for the coverage
pursuant to paragraph three, the participant shall cover the participant and shall cover the alternate
recipients as dependents under an option and coverage category for which the participant and the
alternate recipients are otherwise eligible. Such coverage shall continue for the remainder of the period
described in paragraph four of the Order.
7. Notwithstanding the provisions of paragraph five of this Order, with respect to a participant who is or
becomes a retiree eligible for coverage under the Plan, any election by the participant to assign benefits
payable from a qualified plan for purposes of premium payments under the Plan shall remain revocable to
the extent required by law provided, however, that the alternate recipients’ rights to benefits shall remain
subject at all times to payment of any applicable premiums, regardless of the method of payment.
8. This Order shall be construed and interpreted to provide the alternate recipients with only the types
and forms of benefits, and only the options, that are provided to similarly situated individuals without the
benefit of a QMCSO. Any benefits payable on behalf of an alternate recipient under such option shall be
made payable to the representative.
9. This Order shall not require the Plan to contribute any amount for coverage of an alternate recipient
that exceeds the amount the Plan contributes for similarly situated individuals who are covered under the
Plan without the benefit of a QMCSO.
10. The Alternate Recipient’s Representative and the Petitioner herein,
having been awarded residential custody of the Alternate Recipient, pursuant to ERISA section 609, is
deemed to have been appointed by the Alternate Recipient to receive copies of notices sent to the
Alternate Recipient with respect to this Order.
,
11. Any payment of medical benefits made pursuant to this Order in reimbursement of expenses paid by
an Alternate Recipient or an Alternate Recipient’s custodial parent shall be made to the Alternate Recipient
, as applicable.
or the Alternate Recipient’s residential custodial parent,
12. The Court shall retain jurisdiction to clarify this Order in the event the Plan Administrator raises
questions regarding its interpretation or determines that this Order does not meet the requirements of a
QMCSO under Section 609(a) of ERISA, 29 U.S.C. 1189 in its present form or as hereafter amended.
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13. Copies of the Medical Child Support Order shall be forwarded to the Plan Administrator. The Plan
Administrator shall follow procedures consistent with Section 609(a) of ERISA for determining the qualified
status of this Order.
14. It is ordered that the Clerk of the Court impound this order.
Enter:
Judge
Dated this
day of
, 20
.
Prepared by:
Attorney's Name: _
Address:
State:
City:
Phone:
Zip Code:
Fax:
ARDC:
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