Rev. 11/08 IN THE COURT OF COMMON PLEAS GEAUGA COUNTY, OHIO : CASE NO. ___________________________ : JUDGE ______________________________ Plaintiff/Petitioner vs. : : ORDER (Health Insurance and Expense) ORC §3119.30-.56 Defendant/Petitioner : The Court has determined that ______________________________________ is the party responsible for the health care of the following child(ren): _______________________________ ______________________________________________________________________________. The Court further finds that the following private health insurance and health care policies, contracts, and plans are available at reasonable cost to the Obligor, or Obligee, or both: (List name of insurer, address, responsible party, and policy or contract number) Name of Plan/Insurer ___________________________ ___________________________ ___________________________ Available to: ______________________ ______________________ Policy/Contract # ________________________ ________________________ SECTION I. ORDER ON BOTH OBLIGOR AND OBLIGEE – DUAL COVERAGE (Alternative B-1) The Court finds that private health insurance is accessible and reasonable in cost through a group policy, contract or plan, available to the Obligor through _____________________________________ AND to the Obligee through _______________________________________, and that dual coverage by both parents would provide a coordination of medical benefits without an unnecessary duplication of coverage. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED, in accordance with ORC§3119.30 , that no later than 30 days after the issuance of this support order, both the Obligor and Obligee shall secure and maintain private health insurance coverage for the following child(ren): (names, d.o.b.) ________________________________________________________________________________ ________________________________________________________________________________ -1- American LegalNet, Inc. www.FormsWorkflow.com and shall hereafter be referred to as the Health Insurance Obligors. IT IS FURTHER ORDERED, in accordance with paragraph (C) of ORC §3119.30 that the Child Support Obligor shall pay cash medical support during any period in which the child(ren) named above are not covered by private health insurance pursuant to the support order. ORDER ON OBLIGEE (Alternative B-2) The Court finds that private health insurance is accessible and reasonable in cost through a group policy, contract or plan, available to the Obligee through _________________________ and it is available to the Obligee at a more reasonable cost than any group, policy, contract or plan available to the Obligor. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED, in accordance with ORC§3119.30, that no later than 30 days after the issuance of this support order, the Obligee shall secure and maintain private health insurance coverage for the following child(ren): (names, d.o.b.) ________________________________________________________________________________ ________________________________________________________________________________ and shall hereafter be referred to as the Health Insurance Obligor. IT IS FURTHER ORDERED, in accordance with paragraph (C) of ORC §3119.30 that the Child Support Obligor shall pay cash medical support during any period in which the child(ren) named above are not covered by private health insurance pursuant to the support order. ORDER ON OBLIGOR (Alternative B-3) The Court finds that private health insurance is accessible and reasonable in cost through a group policy, contract or plan available to the Obligor through _________________________ and it is available to the Obligor at a more reasonable cost than any group, policy, contract or plan available to the Obligee. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED, in accordance with ORC§3119.30 , that no later than 30 days after the issuance of this support order, the Obligor shall secure and maintain private health insurance coverage for the following child(ren): (names, d.o.b.) ________________________________________________________________________________ ________________________________________________________________________________ and shall hereafter be referred to as the Health Insurance Obligor. IT IS FURTHER ORDERED, in accordance with paragraph (C) of ORC §3119.30 that the Child Support Obligor shall pay cash medical support during any period in which the child(ren) named above are not covered by private health insurance pursuant to the support order. SECTION II. (Variables) In accordance with paragraph (I) of ORC § 3119.32, upon receipt by the CSED of notice that private health insurance coverage that is reasonable in cost is not available to the Health Insurance Obligor, cash -2- American LegalNet, Inc. www.FormsWorkflow.com medical support shall be paid in the amount determined by the Child Support Computation Worksheet pursuant to ORC §3119.022 and 3119.023. The CSED may change the financial obligations of the parties to pay child support and cash medical support without a hearing or additional notice to the parties. If this box is checked, the cost of private health insurance exceeds the health insurance maximum indicated on line 7b of the Child Support Guidelines Worksheet and: (a) both parents have agreed that one or both of the parents obtain or maintain the private health insurance that exceeds five percent of the annual gross income of the parent obtaining or maintaining the private health insurance or (b) either parent has requested to obtain or maintain the private health insurance that exceeds five percent of that parent’s annual gross income. If this box is checked, the private health insurance is considered accessible when primary care services are not located within 30 miles of the child(ren)’s residence, but are located farther than 30 miles from the child(ren)’s residence because residents, in part, or all of the child(ren)’s immediate geographic area customarily travel farther distances than 30 miles for primary care services. If this box is checked, the custodial parent is dependent upon public transportation; therefore, private health insurance must also provide primary care services that are available by public transportation in order to be considered accessible. SECTION III. NO COVERAGE (Alternate B-4) The Court finds that private health insurance coverage is not accessible or reasonable in cost through any group, policy, contract or plan available to the Child Support Obligor or Child Support Obligee. IT IS FURTHER ORDERED, ADJUDGED AND DECREED in accordance with paragraph (C) of ORC §3119.30 that the Child Support Obligor shall pay cash medical support during the period in which the child(ren) named above are not covered by private health insurance and a Health Insurance Obligor has not been identified. If a Health Insurance Obligor is identified, the Child Support Obligor shall pay cash medical support during any period in which the child(ren) are not covered by private health insurance pursuant to the support order. The cash medical support shall be paid in the amount as determined by the child support computation worksheet pursuant to ORC §3119.022 or 3119.23. IT IS THEREFORE ORDERED, ADJUDGED AND DECREED, in accordance with ORC §3119.30, that if after the issuance of this Order, private health insurance coverage for the child(ren) named above becomes available through any group, policy, contract or plan available to the Child Support Obligor or the Child Support Obligee, the Child Support Obligor or the Child Support Obligee to whom coverage becomes available SHALL IMMEDIATELY INFORM THE CSED OF THE AVAILABLE COVERAGE. When the CSED becomes aware through reporting by either party or by any other means that private health insurance may be available, the CSED will then determine whether the private health insurance coverage is reasonable in cost. When the CSED determines that the private health insurance coverage is reasonable in cost and accessible, the CSED shall notify both parties that the person to whom the coverage is available is now the Health Insurance Obligor and is ordered to secure and maintain private health insurance for the child(ren) named above and to meet the requirements identified under “Notice to -3- American LegalNet, Inc. www.FormsWorkflow.com Health Insurance Obligor” without an additional order or hearing. SECTION IV. UNINSURED MEDICAL COSTS IT IS THEREFORE ORDERED, ADJUDGED AND DECREED that: Obligor,_______________________________________ pay _________% and Obligee _______________________________________ pay __________% of the costs of health care needs of the child(ren) named above that exceed the amount of cash medical support ordered to be paid, when private health insurance is not available or is not being provided in accordance with the support order, OR of the uninsured health care costs or co-payment or deductible costs required under the health insurance policy, contract or plan that covers the child(ren) named above when private health insurance coverage is being provided in accordance with the support order. SECTION V. NOTICE TO THE HEALTH INSURANCE OBLIGOR Within thirty days of the date of this support order, the Health Insurance Obligor/s must designate the child(ren) named above as covered dependents under any health insurance policy, contract or plan for which the Health Insurance Obligor/s contracts. The individuals who are designated to be reimbursed by the health plan administrator for covered out-ofpocket medical, optical, hospital, dental or prescription expenses paid for the child(ren) named above are: Name: Name: Address: Address: The health plan administrator that provides the health insurance coverage for the child(ren) named above may continue making payment for medical, optical, hospital, dental, or prescription services directly to any health care provider in accordance with the applicable health insurance policy, contract or plan. The Health Insurance Obligor may be required to pay the co-payment or deductible costs required under the health insurance policy, contract or plan that covers the child(ren) named above. The Health Insurance Obligor’s employer is required to release to the other parent, any person subject to an order issued under ORC §3109.19 or the CSED on written request any necessary information on the private health insurance coverage, including the name and address of the health plan administrator and any policy, contract or plan number, and to otherwise comply with ORC §3119.32 and any order or notice issued under ORC §3119.32. If the Health Insurance Obligor obtains new employment, the CSED shall comply with the requirements of ORC §3119.34, which may result in the issuance of a notice requiring the new employer to take whatever action is necessary to enroll the child(ren) named above in private health insurance coverage provided by the -4- American LegalNet, Inc. www.FormsWorkflow.com new employer. Within 30 days of the date of this order, the Health Insurance Obligor must provide to the other party information regarding the benefits, limitations and exclusions of the coverage, copies of any insurance forms necessary to receive reimbursement, payment or other benefits under the coverage, and a copy of any necessary insurance cards. IT IS SO ORDERED. __________________________________________ , JUDGE _________________________________ Plaintiff/Petitioner's Attorney _________________________________ _________________________________ _________________________________ Defendant/Petitioner's Attorney _________________________________ _________________________________ Obligor: Obligee: Address: Address: Obligor Employer: Obligee Employer: Address: Address: Obligor Insurer: Obligee Insurer: Address: Address: Policy No.: Policy No.: cc: Geauga County Child Support Division 12480 Ravenwood Drive, P.O. Box 309 Chardon, Ohio 44024 PH. (440) 285-9141 Plaintiff/Petitioner's Attorney Defendant/Petitioner's Attorney -5- American LegalNet, Inc. www.FormsWorkflow.com