MEDICAL SUPPORT

R527-201-9 states:

“(7) In accordance with Subsections 26B-9-225(2) and (3), the parent may contest withholding health insurance premiums based on a mistake of fact. The employer shall continue withholding under the NMSN until notified by ORS to terminate withholding health insurance premiums.”

There may be reasons other than “mistake of fact” why the NMSN action is inappropriate, such as:

1. The NCP/CP previously provided CSS with written proof of enrollment in accordance with the order. Gather the insurance information and add it to ORSIS.

a. If the NCP/CP already has insurance coverage for the child(ren) and provides proof of that coverage, complete the following:

i. Terminate the NMSN by sending the Insurance: Notice to Terminate form to the employer;

ii. Send a copy of the form to the parent providing the insurance; and,

iii. Create a case narrative documenting the reason why the form was sent.

NOTE : When sending a copy of the termination form to the NCP, generate and send the form without the child(ren)’s social security number.

2. Insurance coverage is not available at group rates through the NCP/CP’s employer. The employer should notify CSS by completing and sending in the Employer Response form. If you have not received that information from the employer, call and confirm that information; i.e., verify that the employer does not offer insurance to any of its employees.

3. The total cost of the NCP/CP’s share of the monthly insurance premium has been deemed by CSS to be unreasonable in cost. Senior agents should make a reasonable cost determination only if the NCP/CP requests it through the Written Request for Review National Medical Support Notice.

4. The total cost of the NCP/CP’s share of the monthly insurance premium would exceed the maximum allowable limits.

· The employer notifies CSS that they are currently withholding money to satisfy a child support obligation and the inclusion of a monthly insurance premium amount will cause them to exceed Consumer Credit Protection Act (CCPA) limits; or,

· A parent(s) on a CIC case who has received adoption assistance for a child in the care or custody of the state provides certification from the employer or insurance company that insuring the child would exceed the maximum allowable benefits.

NOTE: Due to the special needs of many children who receive adoption assistance, e.g., extensive counseling, medication, and treatment for psychological disorders, the cost of providing medical and dental insurance for a child who is or was receiving adoption assistance could potentially be unreasonable and, as a result, could max-out the allowable insurance benefits for the remaining individuals covered under the insurance policy.

5. Insurance is not accessible to the child(ren). Non-emergency services covered by the health plan are not accessible to the child(ren) within 90 minutes or 90 miles of the child’s primary residence.

After confirming that the insurance is not accessible to the child(ren) because they reside more than 90 miles or 90 minutes from where non-emergency services covered by the health plan are available,

6. A modification to the child support order no longer requires the parent to maintain insurance for the child(ren).

7. The child(ren) is legally emancipated.

Administrative Review Procedures

The NCP/CP may contest a NMSN by requesting an “administrative review.” An administrative review is outside the formal RAA/UAPA process and gives the NCP/CP the option to try to resolve disputed issues informally with CSS. The administrative review must be made within 15 days of receiving the request for review.

NOTE: An administrative review of the NMSN can be made at anytime following the initial 15 day period if the circumstances have changed AND with manager approval. For example: A NMSN is sent and a review based on unreasonable cost is completed. The cost is found to be reasonable so the NMSN remains in place. A year later the NCP/CP requests another review because his/her monthly insurance premium cost has increased substantially. With the request for a review AND manager approval, another review may be conducted based on the change of circumstance.

If an administrative review is requested, the designated Senior Agent will conduct the review to try and resolve the issue(s) informally. The Senior Agent must complete the review as soon as possible by taking all of the steps listed below.

1. Determine the case in dispute. If the NCP/CP has more than one IV-D case, determine the appropriate case (or cases). If more than one case is involved, handle the review for each case separately.

2. Review the case(s) actions. During the administrative review, the employer must continue to withhold insurance premiums under the NMSN, unless CSS terminates the Notice.

3. Confirm the National Medical Support Notice. Confirm that:

a. The child support order requires the NCP/CP to provide medical insurance for the child(ren);

b. Insurance was available to the NCP/CP through his/her employment at a group rate 30 days prior to the date of mailing the notice; and,

c. The children were not already enrolled in a medical insurance plan.

4. Gather evidence. The NCP/CP must provide CSS with written evidence to support his/her claim. If the evidence is not received within 30 days, proceed with the review and make a determination based on the available facts and evidence.

The NCP/CP does not need to appear in person to provide and/or dispute evidence, but may choose to appear in the office. If the “Request for Review: National Medical Support Notice” has been marked to indicate that the NCP/CP wants to appear in person at the review, send the “Request for Review Appointment Letter” to him/her. If an attorney has been retained, s/he may also attend the review.

5. Make a determination. Review the available facts and evidence and determine if the NCP/CP’s claims are valid.

6. Generate the “Determination Notice”.

a. Generate and send the “Response to Request for Review: NMSN” to the NCP/CP along with the “Written Request for Review: NMSN”, to allow the NCP/CP the opportunity to request an adjudicative proceeding.

NOTE: When/if you review more than one case for the NCP, generate forms for each case. Send the notice(s) by first-class mail.
The form gives the NCP/CP:

i. the results of the administrative review; and,

ii. explains the options for appeal. The NCP/CP may appeal the decision by making a written request for an adjudicative proceeding or by filing a court action. For more information on both these options, refer to the appropriate corresponding section below.

b. Mail the documents to the NCP/CP by first-class mail.

7. Take the appropriate follow-up action. Depending on the outcome of the review, take the next appropriate follow-up action; e.g., update ORSIS and the medical screens, send any new or modified forms that may be necessary based on the determination, which may include sending a new NMSN or terminating the NMSN. R527-201-9 states:

“(8) If a parent successfully contests the action to enroll the children in a health insurance plan based on a mistake of fact, ORS shall notify the employer to discontinue enrollment and withholding health insurance premiums for the children.”

8. Write a case narrative. Write a detailed narrative for each case you reviewed. Include the determination and all of the actions taken on the case(s).

Adjudicative Proceeding Procedures

The NCP/CP may request an adjudicative proceeding under UAPA within 15 days of receiving the NMSN or within 15 days of receiving the “Response to Request for Review: NMSN.” If an adjudicative proceeding is requested, the responsible agent or Presiding Officer (PO) is responsible to complete the following:

1. Review the case for appropriate collection and enforcement actions. During the review time period, the employer must continue withholding insurance premiums, unless CSS terminates the National Medical Support Notice.

2. Compile the state’s evidence. Gather the facts and evidence from the CSS case narratives and any necessary documents from Content Manager records and present it to the PO.

3. Presiding Officer responsibilities.

a. Confirm the National Medical Support Notice. Confirm that:

i. The child support order requires the NCP/CP to provide medical insurance for the child(ren);

ii. Insurance was available to the NCP/CP through his/her employment at a group rate 30 days prior to the date of mailing the notice; and,

iii. The children were not already enrolled in a medical insurance plan.

b. Gather the NCP/CP/s evidence. The NCP/CP must provide written evidence to support his/her claim. If you do not receive the evidence within 30 days from the date of the request, proceed with the review and make a determination based on the available facts and evidence.

If the NCP/CP marks the “Request for Review: National Medical Support Notice”, send the “Request for Review Appointment Letter”. The “Request for Review Appointment Letter” informs the NCP/CP of the date and time of the review. If an attorney has been retained, s/he may also appear.

c. Notify the other party and gather the other party’s evidence, if appropriate. Send the “Notice of Adjudicative Proceeding: NMSN” or the “Noncustodial Parent Notice of Adjudicative Proceeding: NMSN” to the other party by first class mail. The notice informs the other party of the proposed action and invites him/her to present his/her own evidence or documentation. The notice is optional on IV-A cases and is not required on Children in Care (CIC) cases.

The other party does not need to appear in person to present or dispute their evidence or documentation, but may choose to appear with the contesting party or separately, to present evidence and/or review and dispute the other party’s evidence. If an attorney has been retained, s/he may also appear at the review.

d. Make a determination and issue a Decision and Order.

i. Review all of the facts and evidence presented by the agent, the requesting party, and the other party to make a determination.

ii. Generate and issue the appropriate Decision and Order for each case, as listed below.

A. NCP: “Decision and Order: Adjudicative Proceeding, NMSN, Noncustodial Parent”.

B. CP: “Decision and Order: Adjudicative Proceeding, NMSN, Custodial Parent”.

The Decision and Order notifies the NCP/CP of the adjudicative proceeding decision and of his/her options for appeal. The NCP/CP may request reconsideration of the Decision and Order or file a court action. For more information on both of these options, refer to the appropriate corresponding sections below.

e. Process the Decision and Order.

i. Sign and date the order. The order allows the NCP/CP 20 days to request reconsideration of the determination. Include the “Decision and Order Cover Letter”.

ii. Mail by first class mail or deliver a copy of the order personally to the NCP/CP. Include the “Decision and Order Cover Letter”.

iii. Mail by first class mail a copy of the order to the other party. Include the “Courtesy Copy of Administrative Order”.

iv. Mail by first class mail a copy of the order to the:

A. NCP/CP’s attorney if s/he is represented by legal counsel; and/or,

B. the initiating state on an incoming interstate case.

f. Take the appropriate follow-up actions. Depending on the outcome of the review, take the next appropriate follow-up action; e.g., update ORSIS and the appropriate medical screens, send any new or modified forms that may be necessary based on the determination, which may include sending a new NMSN or terminating a NMSN. R527-201-9 states:

g. Write a case narrative. Document the rationale used for making the decision based on the facts and evidence and any follow-up action taken on the case.

A Decision and Order that has been issued by CSS is subject to reconsideration if the NCP/CP makes a written request within 20 days after the Decision and Order was issued.

Reconsideration Procedures

Decision and Orders that have been issued by CSS are subject to reconsideration if a written request is made in within 20 days of issuing the Decision and Order. A reconsideration request does not have a specific form, but must be in writing and must state specific grounds upon which relief is requested.

If you receive a request for reconsideration, forward the request to the Presiding Officer responsible for the Decision and Order. The PO is responsible for taking the steps listed below.

1. Review the case for appropriate actions. During the review period the employer must continue withholding insurance premiums under the, unless CSS terminates the National Medical Support Notice.

2. Grant or deny the reconsideration request.

a. Deny Reconsideration: If you deny the request for reconsideration, complete the following:

i. Issue the “Order: RAA Reconsideration Denied”. Sign and date the order.

ii. Mail a copy of the order to the NCP/CP and the other party. Include the “Courtesy Copy of Administrative Order”.

NOTE: The ORDN provides the NCP/CP with information about his/her options for appeal.

b. Grant Reconsideration: If you grant the request for reconsideration, complete the following:

i. Issue the “Order: RAA Reconsideration Granted”/“Order: RAA Reconsideration Granted”.

ii. Review the facts and evidence of the case, as well as any new pertinent information received from the applicant/recipient.

iii. Issue the “Order Based on Reconsideration: Non-cooperation”. The “Order Based on Reconsideration: Non-cooperation” affirms or amends the original “Decision and Order”.

NOTE: A conference may be conducted to facilitate full reconsideration.

iv. Mail by first class mail or deliver a copy of the order personally to the NCP/CP.

v. Mail by first class mail a copy of the order to the other party. Include the “Custodial Parent Notice of Reconsideration” or the “Noncustodial Parent Notice of Reconsideration”. This notice informs the other party that reconsideration has been granted and invites the other party to present any new or additional information.

The NCP and CP are not required to appear in person to present the new evidence, but they may choose to appear, separately or together, to review and dispute each other’s evidence.

vi. Mail by first class mail a copy of the order to the:

A. NCP/CP’s attorney if s/he is represented by legal counsel; and/or send,

B. the initiating state on an incoming interstate case.

c. Neither Grant nor Deny Reconsideration: If the request for reconsider is not granted or denied with 20 days, the request is considered denied and the original Decision and Order stands.

3. Take the appropriate follow-up actions. Depending on the outcome of the review, take the next appropriate follow-up action; e.g., update ORSIS and the medical screens, send any new or modified forms that may be necessary based on the determination, which may include sending a new NMSN or terminating a NMSN. R527-201-9 states:

4. Write a case narrative. Document all the actions taken on the case(s) and the reason(s) for those actions.

If the NCP/CP wants to appeal the reconsideration decision or the new order based on reconsideration, s/he may file a court action. Reconsideration is not a prerequisite for a court action.

Procedures Court Action Filed

The NCP/CP may choose to file his/her own court action instead of, or in addition to, requesting an administrative review or an adjudicative proceeding. The NCP/CP must provide CSS with evidence that an action has been filed. The evidence of the filing will generally be notice of the legal pleadings. Once you are notified of the filing, send a referral packet to the Attorney General’s Office (AGO).