NATIONAL MEDICAL SUPPORT NOTICE PART A NOTICE TO WITHHOLD FOR HEALTH CARE COVERAGE This Notice is issued under section 466(a)(19) of the Social Security Act, section 609(a)(5)(C) of the Employee Retirement Income Security Act of 1974 (ERISA), and for State and local government and church plans, sections 401(e) and (f) of the Child Support Performance and Incentive Act of 1998. Issuing Agency: __________________________ Issuing Agency Address: ___________________ ________________________________________ Date of Notice: _______________________ Case Number: ________________________ Telephone Number: ___________________ FAX Number: _________________________ Court or Administrative Authority: ___________________________ Date of Support Order: _____________________ Support Order Number: ____________________ _____________________________________) Employer/Withholder’s Federal EIN Number RE* _______________________________________ Employee’s Name (Last, First, MI) _____________________________________) Employer/Withholder’s Name _______________________________________ Employee’s Social Security Number _____________________________________) Employer/Withholder’s Address _______________________________________ Employee’s Mailing Address _____________________________________) Custodial Parent’s Name (Last, First, MI) _____________________________________) Custodial Parent’s Mailing Address _______________________________________ Substituted Official/Agency Name and Address _____________________________________) Child(ren)’s Mailing Address (if different from Custodial Parent’s) _____________________________________) _____________________________________) _____________________________________) Name, Mailing Address, and Telephone Number of a Representative of the Child(ren) Child(ren)’s Name(s) __________________________ __________________________ __________________________ DOB SSN _______ ________ _______ ________ _______ ________ Child(ren)’s Name(s) ____________________________ ____________________________ ____________________________ DOB SSN _________ __________ _________ __________ _________ __________ The order requires the child(ren) to be enrolled in [ ] any health coverages available; or [ ] only the following coverage(s): __Medical; __Dental; __Vision; __Prescription drug; __Mental health; __Other (specify):______________________________ THE PAPERWORK REDUCTION ACT OF 1995 (P.L. 104-13) Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. OMB control number: 0970-0222 Expiration Date: 12/31/2003. American LegalNet, Inc. www.USCourtForms.com EMPLOYER RESPONSE If either 1, 2, or 3 below applies, check the appropriate box and return this Part A to the Issuing Agency within 20 business days after the date of the Notice, or sooner if reasonable. NO OTHER ACTION IS NECESSARY. If neither 1, 2, nor 3 applies, forward Part B to the appropriate plan administrator(s) within 20 business days after the date of the Notice, or sooner if reasonable. Check number 4 and return this Part A to the Issuing Agency if the Plan Administrator informs you that the child(ren) is/are enrolled in an option under the plan for which you have determined that the employee contribution exceeds the amount that may be withheld from the employee’s income due to State or Federal withholding limitations and/or prioritization. 1. Employer does not maintain or contribute to plans providing dependent or family health care coverage. 2. The employee is among a class of employees (for example, part -time or non-union) that are not eligible for family health coverage under any group health plan maintained by the employer or to which the employer contributes. 3. Health care coverage is not available because employee is no longer employed by the employer: Date of termination: _______________________________ Last known address: _______________________________ Last known telephone number: _______________________ New employer (if known): __________________________ New employer address: _____________________________ New employer telephone number: ____________________ 4. State or Federal withholding limitations and/or prioritization prevent the withholding from the employee’s income of the amount required to obtain coverage under the terms of the plan. Employer Representative: Name: ___________________________________ Telephone Number: _____________ Title: ___________________________________ Date: ________________ EIN (if not provided by Issuing Agency on Notice to Withhold for Health Care Coverage): _________________ American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS TO EMPLOYER This document serves as notice that the employee identified on this National Medical Support Notice is obligated by a court or administrative child support order to provide health care coverage for the child(ren) identified on this Notice. This National Medical Support Notice replaces any Medical Support Notice that the Issuing Agency has previously served on you with respect to the employee and the children listed on this Notice. The document consists of Part A - Notice to Withhold for Health Care Coverage for the employer to withhold any employee contributions required by the group health plan(s) in which the child(ren) is/are enrolled; and Part B - Medical Support Notice to the Plan Administrator, which must be forwarded to the administrator of each group health plan identified by the employer to enroll the eligible child(ren). EMPLOYER RESPONSIBILITIES 1. If the individual named above is not your employee, or if family health care coverage is not available, please complete item 1, 2, or 3 of the Employer Response as appropriate, and return it to the Issuing Agency. NO FURTHER ACTION IS NECESSARY. 2. If family health care coverage is available for which the child(ren) identified above may be eligible, you are required to: a. Transfer, not later than 20 business days after the date of this Notice, a copy of Part B - Medical Support Notice to the Plan Administrator to the administrator of each appropriate group health plan for which the child(ren) may be eligible, and b. Upon notification from the plan administrator(s) that the child(ren) is/are enrolled, either 1) withhold from the employee’s income any employee contributions required under each group health plan, in accordance with the applicable law of the employee’s principal place of employment and transfer employee contributions to the appropriate plan(s), or 2) complete item 4 of the Employer Response to notify the Issuing Agency that enrollment cannot be completed because of prioritization or limitations on withholding. c. If the plan administrator notifies you that the employee is subject to a waiting period that expires more than 90 days from the date of its receipt of Part B of this Notice, or whose duration is determined by a measure other than the passage of time (for example, the completion of a certain number of hours worked), notify the plan administrator when the employee is eligible to enroll in the plan and that American LegalNet, Inc. www.USCourtForms.com this Notice requires the enrollment of the child(ren) named in the Notice in the plan. LIMITATIONS ON WITHHOLDING The total amount withheld for both cash and medical support cannot exceed ___% of the employee’s aggregate disposable weekly earnings. The employer may not withhold more under this National Medical Support Notice than the lesser of: 1. The amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C., section 1673(b)); 2. The amounts allowed by the State of the employee’s principal place of employment; or 3. The amounts allowed for health insurance premiums by the child support order, as indicated here:_________________________________. The Federal limit applies to the aggregate disposable weekly earnings (ADWE). ADWE is the net income left after making mandatory deductions such as State, Federal, local taxes; Social Security taxes; and Medicare taxes. PRIORITY OF WITHHOLDING If withholding is required for employee contributions to one or more plans under this notice and for a support obligation under a separate notice and available funds are insufficient for withholding for both cash and medical support contributions, the employer must withhold amounts for purposes of cash support and medical support contributions in accordance with the law, if any, of the State of the employee’s principal place of employment requiring prioritization between cash and medical support, as described here:___________________________________ ______________________________________________________________________. DURATION OF WITHHOLDING The child(ren) shall be treated as dependents under the terms of the plan. Coverage of a child as a dependent will end when similarly situated dependents are no longer eligible for coverage under the terms of the plan. However, the continuation coverage provisions of ERISA may entitle the child to continuation coverage under the plan. The employer must continue to withhold employee contributions and may not disenroll (or eliminate coverage for) the child(ren) unless: 1. The employer is provided satisfactory written evidence that: a. The court or administrative child support order referred to above is no longer in effect; or American LegalNet, Inc. www.USCourtForms.com b. 2. The child(ren) is or will be enrolled in comparable coverage which will take effect no later than the effective date of disenrollment from the plan; or The employer eliminates family health coverage for all of its employees. POSSIBLE SANCTIONS An employer may be subject to sanctions or penalties imposed under State law and/or ERISA for discharging an employee from employment, refusing to employ, or taking disciplinary action against any employee because of medical child support withholding, or for failing to withhold income, or transmit such withheld amounts to the applicable plan(s) as the Notice directs. NOTICE OF TERMINATION OF EMPLOYMENT In any case in which the above employee’s employment terminates, the employer must promptly notify the Issuing Agency listed above of such termination. This requirement may be satisfied by sending to the Issuing Agency a copy of any notice the employer is required to provide under the continuation coverage provisions of ERISA or the Health Insurance Portability and Accountability Act. EMPLOYEE LIABILITY FOR CONTRIBUTION TO PLAN The employee is liable for any employee contributions that are required under the plan(s) for enrollment of the child(ren) and is subject to appropriate enforcement. The employee may contest the withholding under this Notice based on a mistake of fact (such as the identity of the obligor). Should an employee contest the withholding under this Notice, the employer must proceed to comply with the employer responsibilities in this Notice until notified by the Issuing Agency to discontinue withholding. To contest the withholding under this Notice, the employee should contact the Issuing Agency at the address and telephone number listed on the Notice. With respect to plans subject to ERISA, it is the view of the Department of Labor that Federal Courts have jurisdiction if the employee challenges a determination that the Notice constitutes a Qualified Medical Child Support Order. CONTACT FOR QUESTIONS If you have any questions regarding this Notice, you may contact the Issuing Agency at the address and telephone number listed above. American LegalNet, Inc. www.USCourtForms.com NATIONAL MEDICAL SUPPORT NOTICE OMB NO. 1210-0113 PART B MEDICAL SUPPORT NOTICE TO PLAN ADMINISTRATOR This Notice is issued under section 466(a)(19) of the Social Security Act, section 609(a)(5)(C) of the Employee Retirement Income Security Act of 1974, and for State and local government and church plans, sections 401(e) and (f) of the Child Support Performance and Incentive Act of 1998. Receipt of this Notice from the Issuing Agency constitutes receipt of a Medical Child Support Order under applicable law. The rights of the parties and the duties of the plan administrator under this Notice are in addition to the existing rights and duties established under such law. Issuing Agency: __________________________ Issuing Agency Address: ___________________ ________________________________________ Date of Notice: _______________________ Case Number: ________________________ Telephone Number: ___________________ FAX Number: __________________ Court or Administrative Authority: ___________________________ Date of Support Order: _____________________ Support Order Number: ____________________ _____________________________________) Employer/Withholder’s Federal EIN Number RE* _______________________________________ Employee’s Name (Last, First, MI) _____________________________________) Employer/Withholder’s Name _______________________________________ Employee’s Social Security Number _____________________________________) Employer/Withholder’s Address _______________________________________ Employee’s Address _____________________________________) Custodial Parent’s Name (Last, First, MI) _____________________________________) Custodial Parent’s Mailing Address _______________________________________ Substituted Official/Agency Name and Address _____________________________________) Child(ren)’s Mailing Address (if Different from Custodial Parent’s) _____________________________________) _____________________________________) _____________________________________) Name(s), Mailing Address, and Telephone Number of a Representative of the Child(ren) Child(ren)’s Name(s) __________________________ __________________________ __________________________ DOB SSN _______ ________ _______ ________ _______ ________ Child(ren)’s Name(s) ____________________________ ____________________________ ____________________________ DOB SSN _________ __________ _________ __________ _________ __________ The order requires the child(ren) to be enrolled in [] any health coverages available; or [] only the following coverage(s): __medical; __dental; __vision; __prescription drug; __mental health; __other (specify):______________________________ American LegalNet, Inc. www.USCourtForms.com PLAN ADMINISTRATOR RESPONSE (To be completed and returned to the Issuing Agency within 40 business days after the date of the Notice, or sooner if reasonable) This Notice was received by the plan administrator on________. 1. This Notice was determined to be a " qualified medical child support order," on _______. Response 2 or 3, and 4, if applicable. Complete 2. The participant (employee) and alternate recipient(s) (child(ren)) are to be enrolled in the following family coverage. a. The child(ren) is/are cu rrently enrolled in the plan as a dependent of the participant. b. There is only one type of coverage provided under the plan. The child(ren) is/are included as dependents of the participant under the plan. c. The participant is enrolled in an option that is providing dependent coverage and the child(ren) will be enrolled in the same option. d. The participant is enrolled in an option that permits dependent coverage that has not been elected; dependent coverage will be provided. Coverage is effective as of __/__/____(includes waiting period of less than 90 days from date of receipt of this Notice). The child(ren) has/have been enrolled in the following option: _______________________. Any necessary withholding should commence if the employer determines that it is permitted under State and Federal withholding and/or prioritization limitations. 3. There is more than one option available under the plan and the participant is not enrolled. The Issuing Agency must select from the available options. Each child is to be included as a dependent under one of the available options that provide family coverage. If the Issuing Agency does not reply within 20 business days of the date this Response is returned, the child(ren), and the participant if necessary, will be enrolled in the plan’s default option, if any: _______________________________________. 4. The participant is subject to a waiting period that expires __/__/____ (more than 90 days from the date of receipt of this Notice), or has not completed a waiting period which is determined by some measure other than the passage of time, such as the completion of a certain number of hours worked (describe here: _________________________). At the completion of the waiting period, the plan administrator will process the enrollment. 5. This Notice does not constitute a "qualified medical child support order" because: The name of the child(ren) or participant is unavailable. The mailing address of the child(ren) (or a substituted official) or participant is unavailable. The following child(ren) is/are at or above the age at which dependent s are no longer eligible for coverage under the plan _______________________________ (insert name(s) of child(ren)). Plan Administrator or Representative: Name: ___________________________________ Telephone Number: _____________ Title: Date: ________________ ___________________________________ Address: ________________________________ American LegalNet, Inc. www.USCourtForms.com INSTRUCTIONS TO PLAN ADMINISTRATOR This Notice has been forwarded from the employer identified above to you as the plan administrator of a group health plan maintained by the employer (or a group health plan to which the employer contributes) and in which the noncustodial parent/participant identified above is enrolled or is eligible for enrollment. This Notice serves to inform you that the noncustodial parent/participant is obligated by an order issued by the court or agency identified above to provide health care coverage for the child(ren) under the group health plan(s) as described on Part B. (A) If the participant and child(ren) and their mailing addresses (or that of a Substituted Official or Agency) are identified above, and if coverage for the child(ren) is or will become available, this Notice constitutes a “qualified medical child support order” (QMCSO) under ERISA or CSPIA, as applicable. (If any mailing address is not present, but it is reasonably accessible, this Notice will not fail to be a QMCSO on that basis.) You must, within 40 business days of the date of this Notice, or sooner if reasonable: (1) Complete Part B - Plan Administrator Response - and send it to the Issuing Agency: (a) if you checked Response 2: (i) notify the noncustodial parent/participant named above, each named child, and the custodial parent that coverage of the child(ren) is or will become available (notification of the custodial parent will be deemed notification of the child(ren) if they reside at the same address); (ii) furnish the custodial parent a description of the coverage available and the effective date of the coverage, including, if not already provided, a summary plan description and any forms, documents, or information necessary to effectuate such coverage, as well as information necessary to submit claims for benefits; (b) if you checked Response 3: (i) if you have not already done so, provide to the Issuing Agency copies of applicable summary plan descriptions or other documents that describe available coverage including the additional participant contribution necessary to obtain coverage for the child(ren) under each option and whether there is a limited service area for any option; (ii) if the plan has a default option, you are to enroll the child(ren) in the default option if you have not received an election from the Issuing Agency within 20 business days of the date you returned the Response. If the plan does not have a default option, you are to enroll the child(ren) in the option selected by the Issuing Agency. American LegalNet, Inc. www.USCourtForms.com (c) if the participant is subject to a waiting period that expires more than 90 days from the date of receipt of this Notice, or has not completed a waiting period whose duration is determined by a measure other than the passage of time (for example, the completion of a certain number of hours worked), complete Response 4 on the Plan Administrator Response and return to the employer and the Issuing Agency, and notify the participant and the custodial parent; and upon satisfaction of the period or requirement, complete enrollment under Response 2 or 3, and (d) upon completion of the enrollment, transfer the applicable information on Part B Plan Administrator Response to the employer for a determination that the necessary employee contributions are available. Inform the employer that the enrollment is pursuant to a National Medical Support Notice. (B) If within 40 business days of the date of this Notice, or sooner if reasonable, you determine that this Notice does not constitute a QMCSO, you must complete Response 5 of Part B - Plan Administrator Response and send it to the Issuing Agency, and inform the noncustodial parent/participant, custodial parent, and child(ren) of the specific reasons for your determination. (C) Any required notification of the custodial parent, child(ren) and/or participant that is required may be satisfied by sending the party a copy of the Plan Administrator Response, if appropriate. UNLAWFUL REFUSAL TO ENROLL Enrollment of a child may not be denied on the ground that: (1) the child was born out of wedlock; (2) the child is not claimed as a dependent on the participant's Federal income tax return; (3) the child does not reside with the participant or in the plan's service area; or (4) because the child is receiving benefits or is eligible to receive benefits under the State Medicaid plan. If the plan requires that the participant be enrolled in order for the child(ren) to be enrolled, and the participant is not currently enrolled, you must enroll both the participant and the child(ren). All enrollments are to be made without regard to open season restrictions. PAYMENT OF CLAIMS A child covered by a QMCSO, or the child’s custodial parent, legal guardian, or the provider of services to the child, or a State agency to the extent assigned the child’s rights, may file claims and the plan shall make payment for covered benefits or reimbursement directly to such party. PERIOD OF COVERAGE The alternate recipient(s) shall be treated as dependents under the terms of the plan. Coverage of an alternate recipient as a dependent will end when similarly situated dependents are no longer eligible for coverage under the terms of the plan. However, the continuation coverage provisions of ERISA or other applicable law may entitle the alternate recipient to continue coverage under the plan. Once a child is enrolled in the plan as directed above, the alternate recipient may not be disenrolled unless: American LegalNet, Inc. www.USCourtForms.com (1) The plan administrator is provided satisfactory written evidence that either: (a) the court or administrative child support order referred to above is no longer in effect, or (b) the alternate recipient is or will be enrolled in comparable coverage which will take effect no later than the effective date of disenrollment from the plan; (2) The employer eliminates family health coverage for all of its employees; or (3) Any available continuation coverage is not elected, or the period of such coverage expires. CONTACT FOR QUESTIONS If you have any questions regarding this Notice, you may contact the Issuing Agency at the address and telephone number listed above. Paperwork Reduction Act Notice The Issuing Agency asks for the information on this form to carry out the law as specified in the Employee Retirement Income Security Act or the Child Support Performance and Incentive Act, as applicable. You are required to give the Issuing Agency the information. You are not required to respond to this collection of information unless it displays a currently valid OMB control number. The Issuing Agency needs the information to determine whether health care coverage is provided in accordance with the underlying child support order. The Average time needed to complete and file the form is estimated below. These times will vary depending on the individual circumstances. Learning about the law or the form First Notice Subsequent Notices 1 hr. ----- Preparing the form 1 hr., 45 min. 35min. American LegalNet, Inc. www.USCourtForms.com