Form Part A Part A National Medical Support Notice - Part A

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. Receipt of this Notice from the Issuing Agency constitutes receipt of a Medical Child Support Order under applicable law. The information on the Custodial Parent and Child(ren) contained on this page is confidential and should not be shared or disclosed with the employee. NOTE: For purposes of this form, the Custodial Parent may also be the employee when the State opts to enforce against the Custodial Parent.

National Medical Support Order/Notice (NMSN) Termination Order/Notice (Optional)

Issuing Agency: Issuing Agency Address:

Court or Administrative Authority: Order Date:

Order Identifier:

Notice Date: CSE Agency Case Identifier: Telephone Number: FAX Number:

Document Tracking Identifier: Employer web site: See NMSN Instructions: http://www.acf.hhs.gov/programs/css/resource/national- medical-support-notice-form

RE:

Employer/Withholder’s Federal EIN Number

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)

Substituted Official/Agency Name

Custodial Parent’s Mailing Address

Substituted Official/Agency Address

(Required if Custodial Parent’s mailing address is left blank)

Child(ren)’s Mailing Address (if different from Custodial Parent’s)

Name and Telephone of a Representative of the Child(ren)

Child(ren)’s Name(s) Gender DOB SSN

Mailing Address of a Representative of the Child(ren) Child(ren)’s Name(s) Gender DOB SSN

The order requires the child(ren) to be enrolled in all health coverages available; or only the following coverage(s):

0

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: 08/31/2019.

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 income left after making mandatory deductions such as State, Federal, local taxes; Social Security taxes; and Medicare taxes. As required under section 2.b.2 of the Employer Responsibilities on page 4, complete item 5 of the Employer Response to notify the Issuing Agency that enrollment cannot be completed because of prioritization or limitations on withholding.

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: As required under section 2.b.2 of the Employer Responsibilities on page 4, complete item 5 of the Employer Response to notify the Issuing Agency that enrollment cannot be completed because of prioritization or limitations on withholdings.

Additional Information for Termination Order/Notice (Optional)

1. Effective date of medical support termination:

2. Reason for termination: ___________________________________________________________

3. Child(ren) to be terminated:

Child(ren)’s Name(s) (Last, First, Middle DOB

_________________________________ _________________________

_________________________________ _________________________

_________________________________ _________________________

EMPLOYER RESPONSE

If 1, 2, 3, 4 or 5 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 1 through 5 does not apply, complete item 7 and forward Part B to the appropriate Plan Administrator(s) within 20 business days after the date of the Notice, or sooner if reasonable. This includes any organization or labor union that provides group health care benefits to the employee. Check number 5 and return this Part A to the Issuing Agency if the Plan Administrator informs you that the child(ren) would be enrolled in or qualify(ies) for 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. You are required to respond to the Issuing Agency by returning this Employer Response regardless of whether you provide group health benefits or the employee named herein is no longer employed by your organization. Information for the Plan Administrator and the Employer Representative at the bottom of this section is required.

1. The employee named in this Notice has never been employed by this employer.

2. ^{We, the employer, do not offer our employees the option of purchasing dependent or family health care} coverage as a benefit of their employment.

3. 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. Do not check this box if the employee is only temporarily ineligible for health care coverage.

4. ^{Health care coverage is not available because employee is not employed by employer:}

Effective date of termination:

Reason for termination: ___________________________________________________________

Last known telephone number:

Last known address:

New employer (if known):

New employer telephone number:

New employer address:

5. ^{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.

6. ^{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.

7. ^{Employer forwarded Part B to Plan Administrator on .}

MM/DD/YY

CONTACT FOR QUESTIONS

Plan Administrator Name: Contact Person:

FAX Number: Telephone Number:

Employer Name: Employer Representative Name/Title:

Employee Name:

Telephone Number: Federal EIN: (if not provided on Page 1 of this Notice) Date:

INSTRUCTIONS TO EMPLOYER

This document serves as legal 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), or completed by the employer, if the employer serves as the health Plan Administrator.

An employer receiving this legal Notice is required to complete and return Part A – Employer Response. If group health coverage is not available to the employee named herein, or the employee was never or is no longer employed, the employer is required to complete Part A – Employer Response and return it to the Issuing Agency with the appropriate response checked. If you, the employer, provide the health care benefits to the employee, forward Part B – Plan Administrator Response to the health Plan Administrator of your organization. If the employee’s health care benefits are administered through another organization, including a labor union, forward Part B of the Notice to the labor union or other organization acting as the Plan Administrator for completion. If the employee has already enrolled the child(ren) in health care coverage, the employer must forward Part B to the Plan Administrator for completion and submittal to the Issuing Agency.

Keep a copy of Part A as it may be used to notify the Issuing Agency if the employee separates from service for any reason including retirement or termination.

EMPLOYER RESPONSIBILITIES

1. If the individual named in this Notice is not your employee, or if the family health care coverage is not available, please complete item 1, 2, 3, 4 or 5 of the Employer Response as appropriate, and return it to the Issuing Agency. NO OTHER 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:

1. 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, complete item 7, and

2. 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 5 of the Employer Response to notify the Issuing Agency that enrollment cannot be completed because of prioritization or limitations on withholding.

3. 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), complete item 6 of the Employer Response to notify the Issuing Agency of the enrollment timeframe and notify the Plan Administrator when the employee is eligible to enroll in the plan and that this Notice requires the enrollment of the child(ren) named in the Notice in the plan.

1. If the Termination Order/Notice (Optional) checkbox is checked, you are required to terminate the health

care coverage for the child(ren) identified in the order unless the employee has indicated that they want to continue coverage voluntarily.

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 conditions for eligibility for coverage under terms of the plan no longer apply. 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:

   1. The court or administrative child support order referred to in this Notice is no longer in effect; or

   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

2. 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. Sanctions or penalties may be imposed under State law against an employer for failure to respond and/or for non-compliance with this Notice.

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 Part A with response 4 checked or 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 on page 1 of this Notice.

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NMSN - Part A