MEDICAL SUPPORT
CS 490P Enforcement of Medical Insurance
01/90
Revised 09/09/24 Training Completed 09/23/24 Last Reviewed 10/01/24
45 CFR 303.31,
and 303.32;
42 U.S.C. 652(f)
and 666(a)(19);
Utah Code
26B-9-101, 26B-9-201,
26B-9-219,
225, 226, 31A-22-610.5,
31A-45-401,
35A-7-105,
78B-14-502, and 81-6-101;
R527-201
Statutory
Authority
42 U.S.C. 652(f) states:
“The Secretary shall issue regulations to require that
State agencies administering the child support enforcement program under this
part enforce medical support included as part of a child support order whenever
health care coverage is available to the noncustodial parent at a reasonable
cost. . . .”
Utah Code 26B-9-225
states:
“(1) The office may issue a notice to existing and
future employers or unions to enroll a dependent child in an accident and
health insurance plan that is available through the dependent child's parent or
legal guardian's employer or union, when the following conditions are
satisfied:
(a) the parent or legal guardian is already required to obtain
insurance coverage for the child by a prior court or administrative order; and
(b) the parent or legal guardian has failed to provide written
proof to the office that:
(i) the child has been enrolled in an
accident and health insurance plan in accordance with the court or
administrative order; or,
(ii) the coverage required by the order was not available at group
rates through the employer or union 30 or more days prior to the date of the
mailing of the notice to enroll.”
R527-201-9
states:
“(2) If a parent has been ordered to
maintain insurance and insurance is accessible and available at a reasonable
cost, ORS shall use the NMSN to transfer notice of the insurance provision to
the parent's employer unless ORS is notified pursuant to Section 26B-9-225 that
the children are already enrolled in an insurance plan in accordance with the
order.”
Office of Recovery
Services/Child Support Services (ORS/CSS) issues a National Medical Support
Notice (NMSN) to employers to enroll
dependent children in available health insurance plans if the parent is
required to obtain insurance by a court or administrative order and health
insurance has not been obtained.
ORS/CSS will not send a NMSN if the parent provides written proof that
the child has already been enrolled in a health insurance plan or provides
written proof that coverage was not available through the employer 30 or more
days prior to the NMSN date.
If the information is received
from the State Directory of New Hires (SDNH), ORS/CSS must send a National Medical Support Notice
(NMSN) to the employer within two
business days in accordance with Utah Code 35A-7-105(2),
42 USC 666(a)(19) and
45 CFR 303.32, which state:
1.
Utah Code 35A-7-105:
“(2) Beginning May 1, 1998,
within two business days after information described in Section 35A-7-104
is entered into the registry, matched, and reported to the Office of Recovery
Services, the Office of Recovery Services shall transmit a notice to the
employer directing the employer to withhold the employee's wages in an amount
equal to the employee's monthly or other periodic support obligation.”
2.
42 U.S.C. 666(a)(19)(A):
“. . . . all child support orders
enforced pursuant to this part which shall include a provision for medical
support for the child to be provided by either or both parents, and shall be
enforced, where appropriate, through the use of the National Medical Support
Notice promulgated pursuant to section 401(b) of the Child Support Performance
and Incentive Act of 1998 . . .”
3.
45 CFR 303.32:
“(a) Mandatory
State laws. States must have laws, in accordance with section 466(a)(19) of
the Act, requiring procedures specified under paragraph (c) of this section for
the use, where appropriate, of the National Medical Support Notice (NMSN), to
enforce the provision of health care coverage for children of noncustodial
parents and, at State option, custodial parents who are required to provide
health care coverage through an employment-related group health plan pursuant
to a child support order and for whom the employer is known to the State
agency.
(b) Exception.
States are not required to use the NMSN in cases with court or administrative
orders that stipulate alternative health care coverage to employer-based
coverage.
(c) Mandatory
procedures. The State must have in effect and use procedures under which:
(1) The State
agency must use the NMSN to transfer notice of the provision for health care
coverage of the child(ren) to employers.
(2) The State
agency must transfer the NMSN to the employer within two business days after
the date of entry of an employee who is an obligor in a
IV-D case in the State Directory of New Hires.
(3) Employers must
transfer the NMSN to the appropriate group health plan providing any such
health care coverage for which the child(ren) is eligible (excluding the
severable Notice to Withhold for Health Care Coverage directing the employer to
withhold any mandatory employee contributions to the plan) within twenty
business days after the date of the NMSN.
(4) Employers must withhold any obligation of
the employee for employee contributions necessary for coverage of the
child(ren) and send any amount withheld directly to the plan.
(5) Employees may contest the withholding
based on a mistake of fact. If the employee contests such withholding, the employer
must initiate withholding until such time as the employer receives notice that
the contest is resolved.
(6) Employers must notify the State agency
promptly whenever the noncustodial parent's and, at
State option, custodial parent's employment is terminated in the same manner as
required for income withholding cases in accordance with § 303.100(e)(1)(x) of
this part.
(7) The State agency must promptly notify
the employer when there is no longer a current order for medical support in
effect for which the IV-D agency is responsible.
(8) The State agency, in consultation with
the custodial parent, must promptly select from available plan options when the
plan administrator reports that there is more than one option available under
the plan.
(d) Effective date. This section is
effective October 1, 2001, or, if later, the effective date of State laws
described in paragraph (a) of this section. Such State laws must be effective
no later than the close of the first day of the first calendar quarter that
begins after the close of the first regular session of the State legislature
that begins after October 1, 2001. For States with 2-year legislative sessions,
each year of such session would be regarded as a separate regular session.”
NOTE: If you determine that health insurance is
available at a reasonable cost through a
source other than the parent’s employer, you may attempt to enforce the insurance as an optional procedure.
Refer to the
appropriate policies listed below for specific medical support enforcement
requirements.
1.
CS 492P – Manual National Medical Support Notice – Procedures;
2.
CS 493P – Employer/Plan Administrator Responsibility – NMSN; and,
3.
CS 494P – Contesting a National Medical Support Notice.
Definitions
1.
Cash Medical Support – As defined by Utah Code 26B-9-201(5):
“. . . means an obligation to
equally share all reasonable and necessary medical and dental expenses of
children.”
2.
Medical Expenses – As defined by Utah Code 81-6-101(18):
“. . . means health and dental expenses and related insurance
costs.”
3.
National Medical Support Notice
(NMSN): As defined by R527-201-2 Definitions:
“(3)
“National Medical Support Notice (NMSN)” is the federally approved form that
ORS shall use to notify an employer to enroll children in an employment-related
health insurance plan in accordance with a child support order.”
The NMSN is the federally
approved version of the “Notice to Enroll” authorized under:
a.
Utah Code 26B-9-22 Enrollment
of child in accident and health insurance plan – Order – Notice, which states:
“(1) The office may issue a notice
to existing and future employers or unions to enroll a dependent child in an
accident and health insurance plan that is available through the dependent
child's parent or legal guardian's employer or union, when the following
conditions are satisfied:
(a) the parent or legal guardian is already required to obtain insurance
coverage for the child by a prior court or administrative order; and
(b) the parent or legal guardian has failed to provide written proof to the
office that:
(i) the child has been enrolled in an accident and
health insurance plan in accordance with the court or administrative order; or
(ii) the coverage required by the order was not available at group rates
through the employer or union 30 or more days prior to the date of the mailing
of the notice to enroll.”; and,
b.
R527-201-9 Enforcement of Obligation to
Maintain Medical and Dental Insurance, which states:
“(2) If
a parent has been ordered to maintain insurance and insurance is accessible and
available at a reasonable cost, ORS shall use the NMSN to transfer notice of
the insurance provision to the parent's employer unless ORS is notified
pursuant to Section 26B-9-225 that the children are already enrolled in an
insurance plan in accordance with the order.”
Notice to Enroll (NTE) – A legal notice authorized under Utah Code 26B-9-225 and R527-201 and issued to employers or unions to enroll a child(ren) in a group health insurance plan in accordance with a medical support order. Refer to #3 above for more information about the notice to enroll.
5.
Plan Administrator – As defined by CSS for purposes
of using and enforcing the NMSN: The
business agent for a group health plan (the insurer), responsible for enrolling
a child(ren) in a group health insurance plan(s).
6.
Qualified Medical Child Support
Order (QMCSO) – As
defined by CSS and the NMSN for purposes of using and enforcing the NMSN: A medical child support order issued under
state law that creates or recognizes the existence of an “alternate recipients”
right to receive benefits for which a participant or beneficiary is eligible
under a group health plan. A QMCSO satisfies certain additional requirements
contained in the Employee Retirement Income Security Act (ERISA) section 609(a). The NMSN must be considered a QMCSO
as long as insurance is or will become available and it contains the following
information:
a.
The names of
the participant and the child(ren);
b.
The mailing
addresses for all participants; or,
c.
The name and
address of a Substituted Official or Agency; e.g., the CP’s case information
has been safeguarded. When this occurs
the Substituted Official or Agency becomes ORS/CSS with the local office
address.
NOTE: Utah Code 26B-9-225 states:
“(4) A notice to enroll issued under this section may be
considered a "qualified medical support order" for the purposes of
enrolling a child in a group accident and health insurance plan as defined in
Section 609(a), Federal Employee Retirement Income Security Act of 1974.”
7.
Net
Out-of-Pocket Cost – As defined by CSS for purposes of
calculating reasonable cost: The total
cost a noncustodial parent/custodial parent (NCP/CP) pays each month toward a group health insurance plan which
includes coverage for the dependent child(ren).
NOTE: If the obligated parent receives UPP, you must
first deduct the amount the obligated parent receives each month from Utah’
Premium Partnership for Health Insurance (UPP) from the monthly amount the
obligated parent pays for his/her insurance premium. For more information on UPP, refer to #9
below.
8.
Reasonable Cost – As defined by:
a.
45 CFR
303.31(a)(3) which states:
“Cash medical support or
the cost of health insurance is considered reasonable in cost if the cost to
the parent responsible for providing medical support does not exceed five percent
of his or her gross income or, at State option, a reasonable alternative
income-based numeric standard defined in State law, regulations or court rule
having the force of law or State child support guidelines adopted in accordance
with § 302.56(c) of this chapter.”; and,
b.
R527-201-6
Reasonable Cost of Insurance Premiums:
“(1) Employment related or other group
coverage that does not exceed 5% of the parent's monthly gross income is
generally considered reasonable in cost.”; and,
c.
CSS,
for purposes of calculating if an insurance premium is “reasonable in cost”:
The
net out-of-pocket cost the NCP/CP is
required to pay toward the monthly premium for a group health insurance plan
which includes coverage for the dependent child(ren) is less than 5% of the NCP/CP’s gross monthly income.
EXAMPLE 1:
·
Facts:
w
Obligated parent’s gross monthly income is $2,000.00.
w
The NCP pays $93.00 per month to enroll himself, his
spouse and his child from a previous marriage.
·
Calculations:
w
5% of the obligated parent’s income is $100.00 ($2,000.00 X 5% = $100.00).
w
The monthly net out-of-pocket cost for the family
coverage is $93.00.
·
Result:
w
Since $93.00 is less than $100.00, the
obligated parent’s insurance is considered reasonable
in cost.
EXAMPLE 2:
·
Facts:
w Obligated parent’s gross monthly
income is $2,000.00.
w The NCP pays $135.00 per
month to enroll himself, his spouse and his child from a previous
marriage.
·
Calculations:
w 5% of the obligated
parent’s income is $100.00 ($2,000.00 X 5% =
$100.00).
w The monthly net out-of-pocket
cost for the family coverage is $135.00.
·
Result:
w Since $135.00
is more than $100.00, the obligated parent’s cost for family coverage is
considered unreasonable.
NOTE 1: A group health insurance plan which includes
coverage for the child(ren) may be an “employee plus child(ren)” plan or a
“family plan”. The plan may include
coverage for children that are not on the ORS case.
NOTE 2: Senior agents
should make a reasonable cost determination
only if/when the obligated parent requests it through an administrative
review or the CP requests it because the insurance credit exceeds 50% or more
of the monthly child support amount. For more information, refer to CS 494P
Contesting a National Medical Support Notice.
NOTE 3: When making a reasonable
cost determination, do not deduct an anticipated
insurance credit amount (i.e., the credit has not previously been requested by
the parent) from the monthly premium amount for a group health insurance plan
which includes coverage for the child(ren) in order to calculate net
out-of-pocket cost.
9.
Utah’s
Premium Partnership for Health Insurance (UPP)
– A state program administered by the Department of Health and Human Services
that helps individuals and working families afford monthly insurance
premiums. If the person is eligible for
UPP, s/he must:
a.
First enroll in a
health insurance plan through his/her employer; and,
b.
Provide a copy of
his/her paycheck (each month) to UPP to verify that health insurance premiums
are being deducted.
UPP reimburses the individual up
to $150.00 per adult and $100.00 per child every month. In addition, the individual may receive an
additional $20.00 per child each month if they are enrolled in dental insurance.
If the obligated parent requests an insurance credit and s/he has
enrolled in UPP, you must deduct the amount the obligated parent receives from
UPP from the insurance premium amount.
EXAMPLE 1:
· Facts: The NCP is requesting an insurance credit.
w The NCP pays $350.00 per month for family insurance. The insurance covers the NCP, his spouse, their child, and the NCP’s child on a CSS case.
w The NCP is enrolled in UPP. UPP pays $150.00 each month for the NCP and his spouse and $50.00 each month for their child. The NCP receives $350.00 per month from UPP.
· Calculations: $350.00 (insurance premium) - $350.00 (UPP payment) = $0.00. There is no insurance cost to the NCP for insurance. Therefore, the NCP is not entitled to an insurance credit.
EXAMPLE 2:
· Facts:
w The NCP pays $500.00 per month for family insurance. The insurance covers the NCP, his spouse, their child, and the NCP’s child on a CSS case.
w The NCP is enrolled in UPP. UPP pays $150.00 each month for the NCP and his spouse and $120.00 ($100.00 for medical and $20.00 for dental) each month for their child. The NCP receives $420.00 per month from UPP.
· Calculations: $500.00 (insurance premium) - $420.00 (UPP payment) = $80.00 monthly insurance cost. The NCP’s monthly cost for insurance is $80.00 per month.
w There are four people covered on the insurance policy:
§ NCP;
§ Present spouse;
§ Child with present spouse; and,
§ The child on the CSS case.
w $80.00 divided by 4 = $20.00;
w $20.00 x 1 child (CSS case) = $20.00.
w One half of the child(ren)’s portion (insurance credit) would be $10.00. This is calculated as follows: $20.00 (child’s portion of insurance) divided by 2 [or multiplied by 50% (.50)] = $10.00.
Forms Overview
1. National Medical Support Notice (NMSN) Cover Letter. Send this letter to the NCP/CP with a copy of the NMSN – Part A and the Written Request for Review – National Medical Support Notice.
2. National Medical Support Notice Reminder. Send this letter to the Insurance Plan Administrator as a reminder letter when insurance information is not given to the CP.
3. Insurance Warning Letter. Manually request and send this letter to the parent ordered to provide insurance coverage when:
a. CSS is enforcing this obligation;
b. All of the insurance policies have been ended on ORSIS; and,
c. There is no known insurance available; e.g., no active employer records on ORSIS with insurance available for the obligated parents (i.e., an unemployed or self-employed parent, or insurance through a union).
This
letter notifies the parent ordered to provide insurance that s/he has been
ordered to provide insurance coverage for the child(ren), that s/he should
obtain the coverage, and contact ORS/CSS with the information within 15 days.
4. Failure to Enroll. Send this letter to the employer/plan administrator if you do not receive the plan administrator response within 60 days.
5. National Medical Support Notice (NMSN). A two-part form that is sent to the NCP/CP’s employer to enroll his/her child(ren) in a group health insurance plan.
a. NMSN – Part A: Part A consists of two sections:
i. NMSN – Part A – Notifies the employer to start the process of enrolling the child(ren) in a group insurance plan; and,
ii. Employer Response – The employer completes this form and returns it to CSS if insurance is not available to the NCP/CP, or the NCP /CP has terminated. For more information, refer to CS 493P.
NOTE: The NCP/CP receives a copy of Part A along
with the National Medical Support
Notice (NMSN) Cover Letter and the Written Request for Review: National Medical Support Notice.
b. NMSN – Part B: Part B consists of two sections:
i. NMSN – Part B – The employer must send this form to the appropriate plan administrator(s); and,
ii. Plan Administrator Response – The plan administrator completes this form and returns it to CSS after the child(ren) has been enrolled in a medical insurance program. The form provides CSS with the group insurance program. The form provides CSS with the group insurance information to be added to the ORSIS medical screens.
6. NMSN Termination Order/Notice. Send this form to the NCP/CP’s employer to terminate the NMSN, when appropriate.
7. 60-Day Closure Notice. Send this letter to the Non-IV-A Applicant if s/he does not cooperate with CSS in enforcing medical support.
8. Written Request for Review – National Medical Support Notice. This form is sent to the NCP/CP along with a copy of the NMSN – Part A.
Medical Insurance Enforcement
CSS must enforce
union and employment-related medical insurance coverage for all IV-A
recipients, Non-IV-A Medicaid recipients, and Non-IV-A applicants whenever
possible. This includes all of the cases
that are referred to the Attorney General’s Office (AGO) for criminal
non-support and cases where the NCP/CP is self-employed. If the NCP/CP is self-employed, unemployed,
or may have insurance through a union, send the “Insurance Warning Letter” if
the parent is ordered to provide insurance coverage, CSS is enforcing this
obligation, all the insurance policies have been ended on ORSIS, and there is
no known insurance available (e.g.,
no active employer records on ORSIS with insurance available for the obligated
parents).
EXCEPTIONS: CSS will not enforce medical insurance coverage when
the obligated parent has applied for and is approved for insurance coverage for
the child(ren) through the Children’s Health Insurance Program (CHIP). CHIP is not a Medicaid program but an
alternative health insurance program for those who do not qualify for
Medicaid.
The Department of Health and Human Services (DHHS) administers the CHIP program
and determines CHIP eligibility. If a
parent has access to health insurance coverage through an employer, but the
cost to enroll the child(ren) is 5% or more of the household’s gross income,
DHHS will determine that the child(ren) do not
have access to employment related insurance and will qualify them for
CHIP. Once DHHS qualifies the child(ren)
for CHIP, CSS accepts the DHHS determination and will not pursue medical
support enforcement from that parent
until a new employer or group related insurance is or becomes available.
NOTE: If the child(ren) is
eligible to receive medical care through Indian Health Services treat the case
as you would a CHIP case.
If the other parent (not receiving CHIP):
1.
Is
not obligated to provide coverage,
determine if the medical portion of the order should be modified and refer the case
on ORSIS to the modification team, if appropriate; For
more information, refer to CS 451P Review and Adjustment of a Support Order to
Include MEDICAL Support Only; or,
2.
Is
obligated but employment-related insurance is not available at a reasonable cost,
write a case narrative to document the insurance coverage; or,
3.
Has
coverage available but it would not be accessible to the child(ren) (primarily
out-of-state). Write a case narrative to
document the insurance coverage.
Timeframe – Enforcement
If appropriate, you must manually
send:
1. An NMSN to the NCP/CP’s employer within two business days of gathering and receiving new employment information from the SDNH. If the information is received from a source other than SDNH, you must send an NMSN within 30 days of identifying insurance is available.
2. An “Insurance Warning Letter” to the obligate party within 30 days when appropriate.
Enforcement Option – National
Medical Support Notice (NMSN)
An NMSN issued by CSS
is considered to be a qualified medical child support order (QMCSO) for the
purpose of enrolling a dependent child in an insurance plan.
Utah State
law found at Utah Code 26B-9-225 states:
“(1) The office may issue a notice to existing and future
employers or unions to enroll a dependent child in an accident and health
insurance plan that is available through the dependent child's parent or legal
guardian's employer or union, when the following conditions are satisfied:
(a) the parent or legal guardian is already required to obtain
insurance coverage for the child by a prior court or administrative order; and
(b) the parent or legal guardian has failed to provide written
proof to the office that:
(i) the child has been enrolled in an accident
and health insurance plan in accordance with the court or administrative order;
or
(ii) the coverage required by the order was not available at group
rates through the employer or union 30 or more days prior to the date of the
mailing of the notice to enroll.”
NOTE: The obligated party may only use this defense
one-time (not providing CSS with
written proof). For example, the first
time a NMSN is sent to his/her employer after the order is taken.
Utah State
law found at Utah Code 78B-14-502 allows a NMSN to be sent to an out-of-state
employer.
“78B-14-502. Employer's
compliance with income withholding of another state.
(1) Upon receipt of an income-withholding order, the obligor's
employer shall immediately provide a copy of the order to the obligor.
(2) The employer shall treat an income-withholding order issued in
another state which appears regular on its face as if it had been issued by a
tribunal of this state.
(3) Except as otherwise provided in Subsection (4) and Section 78B-14-503, the employer shall withhold and distribute the funds as directed
in the withholding order by complying with terms of the order which specify:
(a) the duration and amount of periodic payments of current
child-support, stated as a sum certain;
(b) the person designated to receive payments and the address to
which the payments are to be forwarded;
(c) medical support, whether in the form of periodic cash payment,
stated as a sum certain, or ordering the obligor to provide health insurance
coverage for the child under a policy available through the obligor's
employment;
(d) the amount of periodic payments of fees and costs for a
support-enforcement agency, the issuing tribunal, and the obligee's
attorney, stated as sums certain; and
(e) the amount of periodic payments of arrearages and interest on
arrearages, stated as sums certain.
(4) An employer shall comply with the law of the state of the
obligor's principal place of employment for withholding from income with
respect to:
(a) the employer's fee for processing an income withholding order;
(b) the maximum amount permitted to be withheld from the obligor's
income; and
(c) the times within which the employer must implement the
withholding order and forward the child-support payment.”
In
accordance with Utah Code 31A-45-401, the employer may not refuse to enroll the
child(ren) because they live outside of the service area. However, the child(ren) are subject to the
out-of-service area contract terms of the insurance policy.
“31A-45-401 Court ordered coverage for
minor children who reside outside the service area.
(1) (a) The requirements of Subsection (2) apply to a managed care
organization if the managed care organization:
(i) restricts coverage for nonemergency
services to services provided by contracted providers within the organization's
service area; and
(ii) does not offer a benefit that permits members the option of
obtaining covered services from a non-network provider.
(b) The requirements of Subsection (2) do not apply to a managed
care organization if:
(i) the child is no longer the subject
of a court or administrative support order; or
(ii) a parent's employer offers the parent a choice to select
health insurance coverage that is not a managed care organization plan either at
the time of the court or administrative support order, or at a subsequent open
enrollment period. This exemption from Subsection (2) applies even if the
parent ultimately chooses the managed care organization plan.
(2) If a parent is required by a court or administrative support
order to provide health insurance coverage for a child who resides outside of a
managed care organization's service area, the managed care organization shall:
(a) comply with the provisions of Section 31A-22-610.5;
(b) allow the enrollee parent to enroll the child on the
organization plan;
(c) pay for otherwise covered health care services rendered to the
child outside of the service area by a non-network provider:
(i) if the child, noncustodial parent,
or custodial parent has complied with prior authorization or utilization review
otherwise required by the organization; and
(ii) in an amount equal to the dollar amount the organization pays
under a noncapitated arrangement for comparable
services to a network provider in the same class of health care providers as
the provider who rendered the services; and
(d) make payments on claims submitted in accordance with
Subsection (2)(c) directly to the provider, custodial parent, the child who
obtained benefits, or state Medicaid agency.
(3) (a) The parents of the child who is the subject of the court
or administrative support order are responsible for any charges billed by the
provider in excess of those paid by the organization.
(b) This section does not affect any court or administrative order
regarding the responsibilities between the parents to pay any medical expenses
not covered by accident and health insurance or a managed care organization
plan.
(4) The commissioner shall adopt rules as necessary to administer
this section and Section 31A-22-610.5.”
“31A-22-610.5. Dependent coverage.
“(1) As used in this section, "child"
has the same meaning as defined in Section 78B-12-102.
(2)(a) Any individual or group accident and health
insurance policy or managed care organization contract that provides coverage
for a policyholder's or certificate holder's dependent:
(i) may not terminate
coverage of an unmarried dependent by reason of the dependent's age before the
dependent's 26th birthday; and
(ii)
shall, upon application, provide coverage for all unmarried dependents up to
age 26.
(b) The cost of coverage for unmarried
dependents 19 to 26 years old shall be included in the premium on the same
basis as other dependent coverage.
(c) This section does not prohibit the employer
from requiring the employee to pay all or part of the cost of coverage for
unmarried dependents.
(d) An individual or group health insurance
policy or managed care organization shall continue in force coverage for a
dependent through the last day of the month in which the dependent ceases to be
a dependent:
(i) if premiums are
paid; and
(ii) notwithstanding Sections 31A-22-618.6 and
31A-22-618.7.
(3)(a) When a parent is required by a court or
administrative order to provide health insurance coverage for a child, an
accident and health insurer may not deny enrollment of a child under the
accident and health insurance plan of the child's parent on the grounds the
child:
(i) was born out of
wedlock and is entitled to coverage under Subsection (4);
(ii) was born out of wedlock and the custodial
parent seeks enrollment for the child under the custodial parent's policy;
(iii) is not claimed as a dependent on the
parent's federal tax return;
(iv) does not reside with the parent; or
(v) does not reside in the insurer's service
area.
(b) A child enrolled as required under
Subsection (3)(a)(iv) is subject to the terms of the accident and health
insurance plan contract pertaining to services received outside of an insurer's
service area.
(4) When a child has accident and health
coverage through an insurer of a noncustodial parent, and when requested by the
noncustodial or custodial parent, the insurer shall:
(a) provide information to the custodial parent
as necessary for the child to obtain benefits through that coverage, but the
insurer or employer, or the agents or employees of either of them, are not
civilly or criminally liable for providing information in compliance with this
Subsection (4)(a), whether the information is provided pursuant to a verbal or
written request;
(b) permit the custodial parent or the service
provider, with the custodial parent's approval, to submit claims for covered
services without the approval of the noncustodial parent; and
(c) make payments on claims submitted in
accordance with Subsection (4)(b) directly to the custodial parent, the child
who obtained benefits, the provider, or the state Medicaid agency.
(5) When a parent is required by a court or
administrative order to provide health coverage for a child, and the parent is
eligible for family health coverage, the insurer shall:
(a) permit the parent to enroll, under the
family coverage, a child who is otherwise eligible for the coverage without
regard to an enrollment season restrictions;
(b) if the parent is enrolled but fails to make
application to obtain coverage for the child, enroll the child under family
coverage upon application of the child's other parent, the state agency Utah
Code Page 2 administering the Medicaid program, or the state agency
administering 42 U.S.C. Sec. 651 through 669, the child support enforcement
program; and
(c) (i) when the
child is covered by an individual policy, not disenroll or eliminate coverage
of the child unless the insurer is provided satisfactory written evidence that:
(A) the court or administrative order is no
longer in effect; or
(B) the child is or will be enrolled in
comparable accident and health coverage through another insurer which will take
effect not later than the effective date of disenrollment; or
(ii) when the child is covered by a group
policy, not disenroll or eliminate coverage of the child unless the employer is
provided with satisfactory written evidence, which evidence is also provided to
the insurer, that Subsection (8)(c)(i), (ii), or
(iii) has happened.
(6) An insurer may not impose requirements on a
state agency that has been assigned the rights of an individual eligible for
medical assistance under Medicaid and covered for accident and health benefits
from the insurer that are different from requirements applicable to an agent or
assignee of any other individual so covered.
(7) Insurers may not reduce their coverage of
pediatric vaccines below the benefit level in effect on May 1, 1993.
(8) When a parent is required by a court or
administrative order to provide health coverage, which is available through an
employer doing business in this state, the employer shall:
(a) permit the parent to enroll under family
coverage any child who is otherwise eligible for coverage without regard to any
enrollment season restrictions;
(b) if the parent is enrolled but fails to make
application to obtain coverage of the child, enroll the child under family
coverage upon application by the child's other parent, by the state agency
administering the Medicaid program, or the state agency administering 42 U.S.C.
Sec. 651 through 669, the child support enforcement program;
(c) not disenroll or eliminate coverage of the
child unless the employer is provided satisfactory written evidence that:
(i) the court order
is no longer in effect;
(ii) the child is or will be enrolled in
comparable coverage which will take effect no later than the effective date of
disenrollment; or
(iii) the employer has eliminated family health
coverage for all of its employees; and
(d) withhold from the employee's compensation
the employee's share, if any, of premiums for health coverage and to pay this
amount to the insurer.
(9) An order issued under Section 26B-9-225 may
be considered a "qualified medical support order" for the purpose of
enrolling a dependent child in a group accident and health insurance plan as
defined in Section 609(a), Federal Employee Retirement Income Security Act of
1974.
(10) This section does not affect any insurer's
ability to require as a precondition of any child being covered under any
policy of insurance that:
(a) the parent continues to be eligible for
coverage;
(b) the child shall be identified to the
insurer with adequate information to comply with this section; and
(c) the premium shall be paid when due.
(11) This section applies to employee welfare
benefit plans as defined in Section 26B-3-1001.
(12) (a) A policy that provides coverage to a
child of a group member may not deny eligibility for coverage to a child solely
because:
(i) the child does
not reside with the insured; or
(ii) the child is solely dependent on a former
spouse of the insured rather than on the insured. Utah Code Page 3
(b) A child who does not reside with the
insured may be excluded on the same basis as a child who resides with the
insured.”
However, if the
employer fails to honor the NMSN, send an intergovernmental referral to the
state and request enforcement. For more
information, refer to CS 222P Intergovernmental Referral Methods.
If the NMSN is sent to an NCP/CP’s employer and the employer
challenges the NMSN on the grounds that the administrative order does not
specify dental coverage should be provided, instruct the employer to only enforce
the medical provision. Refer the case to
the appropriate team for a modification of the order to include a current
medical provision, which orders medical and dental coverage. Manually generate
and send a new NMSN to the employer after the order has been amended. Pursuant to Utah Code 81-6-101(18), “medical
expenses” include health and dental expenses. Therefore, Utah Judicial orders
should not be affected. Refer to CS 451P Review and Adjustment of a Support
Order to Include MEDICAL Support Only.
NOTE: If the CP contacts CSS and indicates that
s/he did not receive this information from the Plan Administrator, send the
“National Medical Support Notice Reminder to the Plan Administrator.” This letter reminds the Plan Administrator to
provide the CP with a description of the available coverage, the effective date
of the coverage, 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.
Failure to Enroll – Procedures
Sixty days after the National
Medical Support Notice was sent to the employer, the agent assigned to the case
receives an alert. If the employer/plan
administrator fails to provide the insurance information or respond in any way,
complete the following:
1. Generate the Failure to Enroll form. This form notifies the employer that the NMSN sent to them previously by CSS:
a. Is authorized under state law found at Utah Code 26B-9-225 and 226;
b. That they are responsible to enroll the dependent child(ren) in an insurance plan; or,
c. The office will be required to take additional action. The employer is given five additional days to provide enrollment information for the child(ren) to prevent further action.
2. Mail the form to the employer.
3. Monitor the case for 15 days for the employer’s response.
4. Write a detailed case narrative documenting all actions taken on the case.
5. Monitor the case for a response. If no response is received within the 15 days, send a referral packet to the appropriate Attorney General’s Office (AGO).
Medical
Support Only Order
If there is an order for medical
support only (no child support ordered), the case must be monitored for medical
enforcement and any appropriate actions taken within the designated time frames
while the case is also going through any necessary order establishment actions.
Intergovernmental
If you are enforcing an order and
the CP is required to provide insurance, but the case is an active outgoing
intergovernmental – CSENet case, you must send a free
form narrative to the other state informing them that the order requires the CP
to provide insurance, not the NCP. When
ORSIS sends the medical insurance information through CSENet,
CSENet only indicates that insurance is ordered, not
the party.
NOTE: If the other state
does not have a copy of the order or has not received a hard copy from CSS,
follow-up by sending a copy of the order.
If the NCP/CP’s current insurance coverage is geographically
limited because the child(ren) [all of the child(ren)] resides outside of the service
area and the child(ren) would realize little or no
benefit by continuing to require the employer to enroll the child(ren) in an
insurance plan:
1. Terminate the NMSN;
2. Update the appropriate fields in ORSIS;
3. Write a case narrative documenting your decision and the reason why you are terminating the NMSN.
Changes in Insurance Coverage
The sections below apply
to all Utah orders, regardless of the date it was issued.
1.
Lapsed Insurance: If the parent that is providing insurance no
longer has insurance available and there was an insurance credit, adjust the
current support debt back to the full amount without seeking a modification of
the order. Retroactively adjust the
current child support arrears to the full child support amount for the months
the parent obligated to provide insurance did not pay the premium.
2.
Premium Increases: If there is a specific insurance credit amount included in the
order and the amount of the premium increases, ORS is bound by the terms of the
order in accordance with State law. If
the NCP and/or CP feel like the terms of the order are no longer valid or
unfair, s/he may pursue the matter in court.
CSS does not have the authority to modify the terms of the order.
3.
Premium Decreases: If there is a specific insurance credit amount included in the
order and the amount of the premium decreases, ORS is bound by the terms of the
order in accordance with State law. If
the NCP and/or CP feel like the terms of the order are no longer valid or
unfair, s/he may pursue the matter
in court. CSS does not have the
authority to modify the terms of the order.
4.
Notification: Notify both parents in writing of changes to
the child support award by generating and sending the "Insurance Premium
Credit Notification" letters.
Insurance Credit
For procedures and more insurance
credit information, including different examples of insurance credit, refer to
CS 407P.
Procedures – Terminating the
National Medical Support Notice
R527-201-9 states:
“(10)
ORS shall promptly notify the employer when a current order for medical support
is no longer in effect for which ORS is responsible”
Send the “NMSN
Termination Order/Notice” to notify an employer to terminate a NMSN.
1.
If
the medical support order is no longer in effect or the NCP/CP successfully
contests the NMSN:
a. Send the “Insurance: Notice to Terminate” form to the employer notifying them that the NMSN is terminated (Option 1);
b. Send a copy of the form to the parent providing the insurance; and,
c. Make a case narrative indicating why the form was sent.
2. If ORS is closing the case and the NCP/CP has no other cases with ORS but there still exists a valid order with medical support language:
a. Send the Insurance: Notice to Terminate form to the employer notifying them that the NMSN is terminated;
b. Send a copy of the form to the parent providing insurance; and,
c. Make a case narrative indicating why the form was sent.