National Medical Support Notice - Part B

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):______________________________

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 currently 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 dependents 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: ________________________________

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.

(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:

(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.
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Preparing the form
1 hr., 45 min.
35 min.