1 of 7 FORM 16.0 0 (effective 3/28/19) LANGUAGE FOR DEPENDENT HEALTH CARE SUPPORT ORDER (To be used with ALL child support orders) PROVISIONS FOR DEPENDENT HEALTH CARE IT IS ORDERED, ADJUDGED and DECREED as follows: Definition as medical, dental, surgical, hospital, prescription drug, optical, orthodontic, mental health, chiropractic, and physical therapy services and char ges which may be reasonable and appropriate to serve the health care needs of a child. accessible private health insurance that provides primary care services within thirty miles from the residence of the child subject to the child support order. child support order, as an amount ordered to be paid in a child support order toward the ordinary obligation is reflected on line 23(b) of the child support worksheet. order as any uninsured medical expenses incurred for a child during a calendar year that exceed the total cash medical support amount owed by the parents during that year. Notification of Illness : Each parent shall promptly notify the other parent of an injury or illness of a child which has necessitated health care, and which occurs while a child is in the care of that parent. The notification shall include an estimate of the cost of any health care expenses incurred, if the parent has such information when the notification American LegalNet, Inc. www.FormsWorkFlow.com 2 of 7 FORM 16.0 0 (effective 3/28/19) is made. Process for Payment of Health Care Expenses : The parent who obtains health care for a child is solely responsible for the submission of the health care bill associated with such care to the insurance company for payme nt. That parent shall submit the health care bill to the insurance company personally, or through the health care provider. If the received by the parent who obtained form. Once the health care bill has been processed by the applicable health care insurance plan, both parents shal l pay their respective share of any uninsured or uncovered health care expense within 45 days of receiving a copy of the explanation of all insurance coverage, whiche ver is later. When a parent pays all (100%) of an out - of - pocket expense, co - pay, deductible or uninsured health care expense, the other parent shall reimburse the paying parent their portion of the expense within 30 days following receipt of a copy of th e paid bill receipt and a Form 8.00 health care expense worksheet. Extraordinary Medical Expenses : In accordance with R.C. 2473119.30 or 2473119.32, the child support o bligor shall pay Percent % and the child support o bligee shall pay Percent % of the costs of the uninsured identified herein, that exceeds the amount of cash medical support owed by the parents during that calendar ye ar . American LegalNet, Inc. www.FormsWorkFlow.com 3 3 of 7 FORM 16.00 (effective 3/28/19) Health Insurance Coverage : [Either A (or its subsections), or B below must be checked] A . Pursuant to R.C. 3119.20 the child support obligee is rebuttably presumed to be the appropriate parent to provide health insurance coverage for the children subject to this child support order and must secure and maintain health insurance for the child(ren) within this child support order, and shall hereinafter be referred to as the health insurance obligor. That presumption can be rebutted only if subsection (1), (2), (3), or (4) is checked below: (1) The child support obligor shall secure and maintain health insurance for the child(ren) within this child support o rder, and shall hereinafter be referred to as the health insurance obligor, as the child support obligor has health insurance coverage available for the child(ren) that is reasonable in cost. (2) The child support obligor shall secure and m aintain health insurance for the child(ren) within this child support order, and shall hereinafter be referred to as the health insurance obl i gor, as t he child support obligor has health insurance coverage in place for the child(ren) that is not re asonable in cost, but the obligor wishes to be named the health insurance obligor and provide coverage under R.C.3119.302(A)(2)(a). (3) The child support obligor shall secure and maintain health insurance for the child(ren) within this child support order, and shall hereinafter be referred to as the health insurance obl i gor, as t he child support obligor can obtain coverage for the child(ren) that is reasonable in cost through an employer or other source. (4) The child support obligee is a non - parent individual or agency that has no duty to provide medical support, and the child support obligor does not have health insurance available at a reasonable cost. American LegalNet, Inc. www.FormsWorkFlow.com 4 4 of 7 FORM 16.00 (effective 3/28/19) OR B . Both the child support obligor and child support oblg ee shall secure and maintain health insurance for the child(ren) within this child support order, and shall hereinafter be referred to as the health insurance obligors because both parents wish to be named health insurance obligors and already have heal th insurance coverage in place or have health insurance coverage available for the children. (Check only if applicable) . Private health insurance coverage is not available at a reasonable cost to the child support obligor or child support oblige e at the time of the issuance of this order. Therefore, pursuant to R.C. 3119.30(B)(2), if health insurance coverage for the child(ren) becomes available at a reasonable co st to the child support obligee, the child support oblige e shall obtain health in surance coverage not later than 30 days after it becomes available at a reasonable cost, and inform CSEA when coverage has been obtained. When private health insurance coverage becomes available to the child support obligor at a reasonable cost, t he child support obligor shall inform the CSEA and may seek a modification of health insurance coverage from the court with respect to a court child support order, or from the agency with respect to an administrative support order. The child suppor t obligor and child support obligee are both liable for the health care expenses for the children who are not covered by private health insurance according to the percentages set forth in the Extraordinary Medical Expenses paragraph above. American LegalNet, Inc. www.FormsWorkFlow.com 5 5 of 7 FORM 16.00 (effective 3/28/19) The child support obligee is dependent upon public transportation; therefore, health insurance must also provide primary care services that are available by public transportation in order to be considered accessible. Private health insurance i s considered accessible when primary care services miles for primary care servic es. Notice to Health Insurance Obligor(s) : 1. Within 30 days of the date of this support order, the Health Insurance Obligor must designate the child(ren) named herein as covered dependents under any health insurance policy, contract, or plan for which the Health Insurance Obligor contracts. 2. The individuals who are designated to be reimbursed by the health plan administrator for covered out - of - pocket medical, optical, hospital, dental, or prescription expenses paid for the child(ren) named herein are: OBLIGOR OBLIGEE NAME: Obligor Name Obligee Name ADDRESS: Obligor Address Obligee Address PHONE: Obligor Phone No. Obligee Phone No. 3. The health plan administrator that provides the health insurance coverage for the American LegalNet, Inc. www.FormsWorkFlow.com 6 6 of 7 FORM 16.00 (effective 3/28/19) child(ren) named herein may continue making payment for medical, optical, hospital, dental, or prescription services directly to any health care provider in accordance with t he applicable health insurance policy, contract or plan. 4. The Health Insurance Obligor may be required to pay co - payment or deductible costs required under the health insurance policy, contract or plan that covers the child(ren) named herein. 5. The Heal parent, any person subject to an order issued under R.C. 2473109.19, or the CSEA upon written request any necessary information on the private healt h insurance coverage, including the name a nd address of the health plan administrator