IN THE COURT OF COMMON PLEAS DIVISION OF DOMESTIC RELATIONS LAKE COUNTY, OHIO ___________________________ Plaintiff -vs____________________________ Defendant ) ) ) ) ) ) ) ) CASE NO. _________________________ JUDGE COLLEEN A. FALKOWSKI HEALTH INSURANCE AND EXPENSE ORDER The Court finds that neither parent has private health insurance coverage available for the child(ren) at a reasonable cost. Pursuant to Ohio Revised Code §3119.30(A) both parents are liable for the health care of the child(ren) who is/are not covered by private health insurance or cash medical support as calculated in accordance with §3119.022 or §3119.023, as applicable. The parents shall share liability for the ordinary and extraordinary health care expenses of the child(ren) who is/are not covered by private health insurance or cash medical support as calculated in accordance with §3119.022 or §3119.023, as applicable, in amounts equal to the percentages indicated on Line 16 of the Child Support Computation Worksheet as follows: Child Support Obligor shall pay _________% and Child Support Obligee shall pay _________%. in accordance with the following formula: ______________________________. The Child Support Obligor and the Child Support Obligee shall immediately inform the CSEA if private health insurance coverage for the child(ren) becomes available to either the Obligor or the Obligee. The CSEA shall determine if the private health insurance is available at a reasonable cost and if coverage is reasonable, order the Obligor or the Obligee to obtain private health insurance. -ORThe Court finds that the mother and/or the father have the following private health insurance coverage available for the child(ren) at a reasonable cost through a group policy, contract, or plan: Insurer: Available to: _______________________________________________ _______________________________________________ Mother Father Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com The Health Insurance Obligor(s), until further order of Court: Mother Father Mother and Father The Health Insurance Obligor(s) shall provide private health insurance through: MOTHER Name Address Telephone No. _______________________ _______________________ _______________________ Name of employer/group/individual Address of employer/group/individual _______________________ _______________________ _______________________ Name of health plan Name of insurance company Claims address of insurance company _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ Customer service telephone number Group number Identification/Subscriber number FATHER Name Address Telephone No. _______________________ _______________________ _______________________ Name of employer/group/individual Address of employer/group/individual _______________________ _______________________ _______________________ Name of health plan Name of insurance company Claims address of insurance company _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ Customer service telephone number Group number Identification/Subscriber number and shall designate the following child(ren) as covered dependents under the private health insurance policy, contract or plan: Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com Full name of each child subject to the Medical Support Order _________________________________________________ _________________________________________________ _________________________________________________ Date of Birth ____________ ____________ ____________ The parents shall share liability for the ordinary and extraordinary health care expenses as defined by §3119.05(F) of the child(ren) not covered by the private health insurance plan as calculated in accordance with §3119.022 or §3119.023, as applicable, in amounts equal to the percentages indicated on Line 16 of the Child Support Computation Worksheet Worksheet as follows: Child Support Obligor shall pay _________% and Child Support Obligee shall pay _________%. in accordance with the following formula: ______________________________. Pursuant to Ohio Revised Code §3119.30 the parent(s) ordered to provide private health insurance for the child(ren) shall, not later than thirty (30) days after the issuance of the order, obtain the insurance and supply the other parent with information regarding the benefits, limitations and exclusions of the health insurance coverage, copies of any insurance forms necessary to receive reimbursement, payment, or other benefits under the health insurance coverage and a copy of any necessary insurance cards. If a parent required to obtain health insurance coverage in accordance with this order does not obtain the required coverage within thirty days after the order is issued, the Child Support Enforcement Agency shall notify the court in writing of the failure of the parent to comply with the child support order. On receipt of the notice from the agency, the court shall issue an order to the employer of the parent required to obtain health insurance coverage, requiring the employer to take whatever action is necessary to make application to enroll the parent required to obtain health insurance coverage in any available group health insurance or health care policy, contract, or plan with coverage for the children, to submit a copy of the child support order to the insurer at the time that the employer makes application to enroll the children in the health insurance or health care policy, contract, or plan, and, if the application is accepted, to deduct from the wages or other income of the parent required to obtain health insurance coverage the cost of the coverage for the children. Upon receipt of any such order, the employer shall take whatever action is necessary to comply with the order. The following individual shall be reimbursed for covered out-of-pocket medical, optical, hospital, dental, orthodontia or prescription expenses paid for the above-named child(ren): Name of party Address Telephone number _________________________________________ _________________________________________ _________________________________________ _________________________________________ Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com The health plan administrator(s) of the health insurer(s) that provide(s) the private health insurance coverage for the child(ren) may continue making payment for medical, optical, hospital, dental, or prescription services directly to any health care provider in accordance with the applicable private health insurance policy, contract, or plan. The employer(s) of the person(s) required to obtain private health insurance coverage is/are required to release to the other parent, any person subject to an order issued under §3109.19 of the Revised Code, or the CSEA, 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 Ohio Revised Code §3119.32 and any order or notice issued under this section. If the person(s) required to obtain private health insurance coverage for the child(ren) subject to this child support order obtain(s) new employment, the agency shall comply with the requirements of section 3119.34 of the Revised Code, which may result in the issuance of a notice requiring the new employer to take whatever action is necessary to enroll the child(ren) in private health insurance coverage provided by the new employer. Any employer who receives a copy of an order issued under Ohio Revised Code §3119.30, §3119.33 or §3119.34 shall notify the CSEA of any change in or the termination of the Child Support Obligor’s or the Child Support Obligee’s private health insurance coverage that is maintained pursuant to the order. Upon receipt of notice by the CSEA that private health insurance coverage is not available at a reasonable cost, cash medical support shall be paid in the amount as determined by the child support computation worksheets in §3119.022 or §3119.023 of the Revised Code, as applicable. The CSEA may change the financial obligations of the parties to pay child support in accordance with the terms of the court order and cash medical support without a hearing or additional notice to the parties. The parties affected by the support order shall inform the CSEA of any change of name or other change of conditions that may affect the administration of the order. Willful failure to inform the CSEA of the above information and any changes is contempt of court. A copy of this order shall be sent by the Clerk via ordinary mail to each parent, their employer and their insurer at the addresses listed above. IT IS SO ORDERED. ___________________________________ COLLEEN A. FALKOWSKI, JUDGE CC: CSEA Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com