Once medical support coverage has been included in an order, or a responsible parent has been ordered to obtain medical support coverage, Federal regulations mandate that steps must be taken to enforce these medical support obligations. The CSS program must also collect and distribute medical support included in previously entered court orders with a specific dollar amount, such as periodic payments or lump-sum payments. The CSS case history should contain complete documentation of all efforts to establish and enforce medical support.
Enforcement procedures must include the following:
VSA: "I hereby agree that I will obtain employment-related health insurance coverage when it is available, and I will notify either the court or the CSS agency in writing when I have obtained the agreed medical support coverage and/or when such coverage is terminated."
Order: "The defendant is hereby ordered to obtain employer-related health insurance coverage when it is available and to notify either the court or CSS agency in writing when the required medical support coverage has been obtained or terminated."
If the NCP fails to obtain health insurance coverage as ordered, caseworkers must use the appropriate enforcement remedies as outlined above.
Also if the NCP fails to obtain the coverage as ordered, allows the coverage to lapse when it was in fact still available, or fails to cover the child at a new employer if it is available, the NCP shall be held liable for medical expenses incurred from the date of the court order, NCGS 50-13.11(E). Upon hearing evidence of the amount of medical expenses incurred and the NCP's failure to provide insurance coverage, the court can order that the NCP be held responsible for the actual expenses incurred.
If medical insurance coverage for the child(ren) is not immediately available, the case must be monitored by the CSS agency and appropriate action taken to obtain coverage if circumstances change.
Other enforcement activities such as monitoring Medicaid claims and payments and pursuing third-party medical support are the responsibility of the State Medicaid Agency.
Monitoring compliance for medical insurance when a non-case participant (such as a grandparent, stepparent, or other relative of the child) provides medical insurance is a manual process. The NCP is compliant with the court order to provide medical insurance if a non-case participant volunteers to provide medical insurance for a dependent, but non-case participants are not required to provide, continue to provide, or notify CSS when no longer providing medical insurance.
Caseworkers should never direct correspondence to a non-case participant or to a non-case participant's employer or insurance provider. ACTS does not generate documents to the non-case participant when non-case participant data is present on the medical insurance record. All correspondence regarding insurance coverage should be sent to the case participant (custodial parent or NCP) who is ordered to provide medical insurance.
Federal regulation 45 CFR 302.51 requires the CSS agency to collect and distribute medical support from a previously established order if the order specifies a dollar amount (EX: an order for $20.00 per month or a $1600.00 lump-sum order for orthodontics). Payments must be directed to the Department of Health and Human Services (DHHS) for distribution to either the custodial parent or to the Division of Medical Assistance (DMA).
NCGS 58-51 prescribes that an insurer shall not deny enrollment in a parent's health benefit plan to a child who:
CSS agencies are often asked to mediate in situations regarding medical support that might not fall under the CSS Program's control or responsibility. The following are typical case situations:
In instances such as these, the CSS agency's responsibility is to enforce health insurance coverage and medical support specifying a dollar amount. Unless it is specifically stated in the court order that the NCP is responsible for the deductible, arranging for a physical, etc., the custodial parent can be held responsible for these additional expenses. Issues related to insurer requirements and the recoupment of any improper reimbursement to an NCP in Medicaid cases are the responsibility of Third Party Recovery. The CSS agency is not involved in the resolution of these matters.
However, in some instances, the CSS agency can take appropriate court action. For example, if an NCP appears to the CSS agency to be evading the medical support obligation by opting for the most restrictive health insurance coverage for the child(ren) when broader options are available through the employer, the CSS agency must enforce this provision. The same would be true if the NCP subsequently obtained dependent insurance coverage that was not employment-related to avoid paying higher premiums or receives reimbursement for expenses that were paid initially by the custodial parent and fails to reimburse the custodial parent. This can be accomplished through a court action or show cause to further delineate the NCP's medical support responsibilities.
The insurer must:
If the insurer denies coverage or other difficulties are encountered, the CSS caseworker should contact the CSS attorney and/or Third Party Recovery before taking action in the matter.
The statute also prescribes that when a parent is ordered to provide health insurance using the dependent coverage available through the employer's benefit plan, the employer must:
ACTS generates the Employer Letter To Verify Continued Insurance Coverage (DSS-4653) ACTS semi-annually. This letter is sent to the verified employers of noncustodial parents (NCPs) who have been ordered to provide dependent medical insurance.
The employer returns verification of whether or not dependent medical insurance coverage is available to the responsible caseworker. Caseworkers must then update the NCP’s employment information in ACTS.
ACTS checks the terms of the current court order to determine if the NCP is required to provide medical insurance for the child(ren). If medical insurance has not been ordered and caseworkers have indicated that it is available, ACTS generates a Medical Insurance Modification Request(DSS-4565). This letter is sent to the NCP and requests that he/she voluntarily agree to provide medical insurance for the child(ren).
If the NCP does not respond in thirty (30) days, caseworkers generate a Motion To Modify Order (DSS-4654) to add dependent medical insurance to the support order. Then caseworkers schedule a court hearing and generate the appropriate hearing notice document(s). When the court makes a decision, caseworkers must update the court order information in ACTS, based on that decision.
When the dependent medical insurance policy end date is reached, that policy is no longer in effect. ACTS checks the current court terms to determine if the NCP has been ordered to provide medical insurance for the child(ren). If the court has ordered the NCP to provide medical insurance for the child(ren) and the policy is no longer in effect, ACTS generates the Demand for Insurance Coverage Compliance (DSS-4494). This document notifies the NCP of his/her failure to provide medical coverage for the child(ren)and advises him/her to acquire medical coverage for the child(ren) within thirty (30) days.
If responsible caseworkers do not receive a response from the NCP within thirty (30) days, they manually generate a Motion/Order To Appear And Show Cause For Medical Insurance (DSS-4642). Caseworkers should also schedule a court hearing and generate the appropriate hearing notice document(s). When the court hears the case and renders a judgment, caseworkers must update the support order information in ACTS, based upon the court's decision.
The National Medical Support Notice (DSS-4733) is a standardized form that Federal regulation 45 CFR 303.32 requires all states to use in enforcing medical child support orders. Tribal CSE agencies are not required to use this form. The Notice provides a means of communication between child support agencies, employers, and group health plan administrators regarding the medical support obligations of NCPs. It also serves as a "qualified medical child support order."
Effective August 1, 2002, when the court orders NCPs to provide employment-related health insurance coverage for their child(ren), the National Medical Support Notice (DSS-4733) must be served on the NCP's employer. Service must occur within five (5) business days after an initial order has been entered, within two (2) business days of the NCP being added to the New Hire Directory, or as soon as caseworkers become aware that the NCP has changed employment.
This notice is not used:
The National Medical Support Notice is divided into two parts and includes four different documents.
After the local CSS agency mails the Notice to the NCP's employer, the employer is required to transfer Part B within twenty (20) business days to the health insurer, health care plan administrator, or other organization (including a labor union) that provides health care benefits to the NCP, unless:
If employers are not required to transfer the Notice due to one of these reasons, they must notify the local CSS agency in writing within twenty (20) business days after the date of the Notice.
If none of these reasons apply, employers forward the Notice to the health insurer or plan administrator or complete the Notice if the employer serves as the plan administrator (at the end of any eligibility waiting period).
If the employee has already enrolled the child(ren) in the plan, employers should contact the local CSS agency to provide coverage information.
If the plan administrator informs the employer that the Notice does not meet their requirements for a "qualified medical child support order," the employer must notify the local CSS agency in writing. If the plan administrator informs the employer of an enrollment waiting period for the employee, the employer must notify the plan administrator when the employee is eligible for enrollment in the health care plan.
If the plan administrator informs the employer that withholding limitations prevent the employer from withholding the amount required to obtain insurance, the employer must then inform the local CSS agency in writing. For more information about withholding limitations, see Maximum Allowable Percentage.
The health insurer or health plan administrator notifies the employer of any applicable enrollment waiting periods, and the employer notifies the local CSS agency of the enrollment time. The plan administrator also notifies the employer about the cost of the dependent coverage. The employer withholds this amount from the NCP's wages and transfers this amount directly to the insurer or plan administrator.
If the NCP/employee contests the withholding, the employer shall initiate and continue the withholding until the employer receives notice that the contested case is resolved.
Employers that are obligated to provide health benefit plan coverage must inform the local CSS agency in writing within ten (10) business days of the NCP's termination of employment. Employers must include the NCP's last known address and telephone number and the name, address, and telephone number of the new employer, if known.
An employer cannot fire, refuse to employ, or take disciplinary action against an NCP solely because of the withholding.
If a court finds that an employer has failed to comply with these provisions, the employer is liable as a payor and liable in a civil action for reasonable damages.
The plan administrator must complete the "Plan Administrator Response" section of Part B and return it to the local CSS agency within forty (40) business days after the date on the National Medical Support Notice. Plan administrators can include the following information:
If more than one health care option is available under the health plan, the insurer or health plan administrator notifies the local CSS agency. The responsible caseworker must consult with the custodial parent, select an option, and inform the plan administrator of the option selected within twenty (20) calendar days from the date when the plan administrator notified the local CSS agency.
If the Notice is determined to be a "qualified medical child support order," the plan administrator enrolls the child(ren), determines the cost of the coverage, and notifies the employer of the amount to be withheld.
The plan administrator notifies the local CSS agency, employer, NCP, and custodial parent of any enrollment waiting periods for the employee. After the waiting period has ended, the plan administrator must enroll the child(ren).
If either the employer, the health insurer, or plan administrator does not comply with these provisions, they can be held liable for a civil penalty and are subject to a civil suit for reasonable damages.
When an NCP is no longer under order to provide medical insurance for the child(ren), the CSS agency enforcing the medical obligation must send a Medical Insurance Termination Notice (DSS-4734) within ten (10) business days to notify the employer(s) of the end of the medical obligation.
ACTS generates the National Medical Support Notice (DSS-4733) when the following conditions are met:
If the court has ordered the noncustodial parent to obtain insurance other than employment-related insurance for the child(ren), CSS DOES NOT send the National Medical Support Notice.
When NCPs contest the medical insurance withholding, caseworkers should advise them that they can hire an attorney at their own expense and file a Motion for Modification with the Clerk of Court. If the court rules that the NCP is not required to provide the employment-related dependent insurance, notify the employer to stop the withholding for the health care premium.
For questions or clarification on any of the policy contained in these manuals, please contact your local county office.