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PA Child Support Program

FAQs about NMSN for Employers and Plan Administrators

National Medical Support Notice FAQ Employer

Last modified on: December 15, 2009

National Medical Support Notice
1. What is the National Medical Support Notice (NMSN)?

The NMSN is a standardized medical child support order that is to be used by state child support enforcement agencies to enforce medical child support obligations whenever a party in a support action is ordered to provide health care insurance for his/her child(ren) and that party is employed or in active military or reserve military duty. The Department of Labor and the Department of Health and Human Services adopted regulations at Title 29 of the Code of Federal Regulations §2590.609-2 and Title 45 of the Code of Federal Regulations §303.32 that implement the NMSN provisions of the Child Support Performance and Incentive Act of 1998.

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2. What does the Child Support Performance and Incentive Act (CSPIA) of 1998 require of state and local governmental and church group health plans?

CSPIA requires church plans to comply with any qualified medical child support orders (QMCSOs), including the NMSN. CSPIA also requires that plans sponsored by state and local governments provide benefits in accordance with the applicable requirements of any NMSN. [CSPIA §401(e)(1) and §410(f)(1)]

In addition, CSPIA provides for the following: the promulgation of the NMSN by mandating that states issue it as a means of enforcing the health care coverage provisions in a child support order; the requirements of the NMSN; the required use of the NMSN by States; and the NMSN being deemed as a qualified medical child support order under the Employee Retirement Income Security Act of 1974 (ERISA). [CSPIA §§(b)(1) and (2), (c) and (d)]

The Department of Labor has no interpretive or enforcement authority over those requirements. [ERISA §609(a)(5)(C); §466(a)(19) of the Social Security Act]

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3. When is a NMSN “appropriately completed”?

An “appropriately completed” NMSN includes the following information:
  • Name of the issuing state child support enforcement agency;
  • Name and mailing address of the employee who is either enrolled or eligible for enrollment in a group health plan and who is obligated by a state court or administrative order to provide medical support for each child named in the order; and,
  • Name and mailing address of each child named in the NMSN. Note that the name and address of a county Domestic Relations Section (DRS) may be substituted for the address of either party in a support action and for the child(ren).

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4. What is a qualified medical child support order (QMCSO)?

The “QMCSO” is a medical child support order that:
  • Creates or recognizes the right of a child named in a child support order, also known as an “alternate recipient,” to receive benefits for which a parent who is the participant or beneficiary eligible under a group health plan or who assigns to an alternate recipient the right of a participant or beneficiary to receive benefits under a group health plan; and,
  • Is recognized by the group health plan as “qualified” because it includes information and meets other requirements of the QMCSO provisions.
The NMSN is a QMCSO and is only to be used by child support enforcement agencies. Entities other than child support enforcement agencies must continue to submit a QMCSO to obtain health care coverage.

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5. What types of plans are subject to QMCSO provisions?

The QMCSO provisions apply to “group health plans” subject to ERISA, as amended. For this purpose, a “group health plan” generally is one that:
  • Is sponsored by an employer or employee organization (or both) and provides “medical care” to employees, former employees or their families. “Medical care” means amounts paid for the diagnosis, cure, mitigation, treatment, or prevention of a disease; for the purpose of affecting any structure or function of the body; transportation primarily for or essential to such care or services; or for insurance covering such care or services.
  • ERISA does not apply to plans maintained by: Federal, State or local governments; churches; and, employers solely for purposes of complying with applicable workers compensation or disability laws. However, CSPIA provisions require church plans to comply with QMCSOs and NMSNs, and State and local government plans to comply with NMSNs. [ERISA §§4(b), 609(a), and 607(1); §213(d) of the Internal Revenue Code; §401(f) of CSPIA]

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6. What information must a medical child support order contain to be a “qualified” order?

A “qualified” medical child support order, or QMCSO, must contain:
  • The name and last known mailing address of the parent who is the participant and each child named in the order, except when the name and mailing address of a State or local official is substituted for the mailing address of an individual;
  • A reasonable description of the type of health coverage to be provided to each child named in the order or the manner in which such coverage is to be determined; and
  • The period to which the order applies.
A medical child support order may not require a plan to provide any type or form of benefit, or any option, not otherwise provided under the plan, except to the extent necessary to meet the requirements of certain State laws. For instance, a NMSN requires a plan to enroll a child without regard to seasonal enrollment restrictions. [ERISA § 609(a)(3)]

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7. Who determines if a NMSN is qualified?

The administrator of the group health plan is required to determine whether an order is qualified. The plan administrator is required to make this determination within a reasonable period of time pursuant to reasonable written procedures that have been adopted by the plan. The plan administrator must first notify the participant and alternate recipient of the receipt when the plan receives a medical child support order and must give them copies of the plan’s procedures for determining whether it is qualified, and then the plan administrator must notify those parties, as well as the Issuing Agency, of its determination whether or not the order is qualified along with the specific reasons for the determination. [ERISA §609(a)(5)]

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8. When does the plan administrator receive the NMSN?

The Issuing Agency will mail an NMSN packet to the employer(s) for each parent ordered to provide health care insurance. The employer must submit the NMSN Part B–Medical Support Notice to Plan Administrator and the Addendum to Part B–Plan Administrator Response to the plan administrator(s) within 20 business days from the date on the NMSN if health care coverage is available for which the child(ren) may be eligible. The employer completes and returns the Addendum to Part A–Employer Response to the Issuing Agency.

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9. How long does the plan administrator have to enroll a child in health care coverage?

The plan administrator has 40 business days from the date on the NMSN to complete the enrollment process and return Part B–Medical Support Notice to Plan Administrator to the Issuing Agency. When there are multiple coverage options available under the plan and the participant is not enrolled, the plan administrator must provide contact name and phone number to the Issuing Agency and wait to be notified of the next steps. The county Court then has 20 business days to tell the plan administrator which coverage option has been selected. [ERISA §609(a)(5)] The plan administrator may return the Medical Support Notice to Plan Administrator and the Plan Administrator Response pages of Part B (first two pages) to the Issuing Agency without the Instructions to Plan Administrator pages.

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10. When must a plan administrator begin to provide health care coverage to a child in accordance with a NMSN?

Following a determination that a NMSN is qualified, the child (and the participant, if necessary) must be enrolled as of the earliest possible date following such determination. For example, if an insurer only adds new participants or beneficiaries as of the first day of each month, the insurer would be required to provide coverage to the child as of the first day of the first month following the determination that the NMSN is qualified. The state laws described in section 1908 of the Social Security Act require that a child who is enrolled into a plan pursuant to a court or administrative order, must be enrolled without regard to open seasonal enrollment restrictions. [§1908 of the Social Security Act]

The plan administrator must notify the parents and child(ren) that coverage is or will become available and must furnish the custodial parent with a description and the effective date of the coverage along with information and documents to achieve the coverage and file claims. The plan administrator must also complete and return the Addendum to Part B–Plan Administrator Response, which includes the health insurance identification data, to the Issuing Agency.

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11. If an employee named in a NMSN is not already enrolled in the plan’s dependent health care coverage, what is the plan administrator’s obligation?

Once the NMSN is determined to be qualified, the plan administrator begins the enrollment process to provide coverage to the child. As long as the employee is eligible to participate in the plan, the child must be covered. If, as a condition for covering his dependents, the employee must be enrolled, the plan administrator must enroll the employee and each child named in the NMSN.

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12. If an employee has not yet satisfied a plan’s generally applicable waiting period, does the NMSN meet the ERISA definition of a QMCSO?

Yes. Because an employee who has not yet satisfied a plan’s generally applicable waiting period (such as requiring that person to be employed for a certain number of days or to work a certain number of hours before being eligible for medical benefits) is still a participant in the plan, the NMSN is deemed a QMCSO by ERISA standards. [ERISA §§3(7) and 609(a)(1)]

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13. In the case of an employee who has not yet satisfied the plan’s generally applicable waiting period, what is the plan administrator’s obligation?

The plan administrator should have procedures in place to enroll the child upon the employee’s satisfaction of the waiting period.

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14. If a group health plan does not provide any dependent coverage, may the NMSN require the plan to provide for a child of a participant pursuant to a QMCSO?

No. A medical child support order is not qualified if it requires a plan to provide a type or form of benefit or option not otherwise available under the plan. Therefore, a NMSN may not require a plan to provide dependent coverage when that option is not otherwise available under the plan. [ERISA §609(a)(4)]

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15. Is the plan administrator required to reject a NMSN as not qualified if the NMSN fails to include factual identifying information that is easily obtainable by the plan administrator?

No. If a NMSN clearly describes the identity and rights of the parties, but is incomplete only with respect to factual identifying information within the plan administrator’s knowledge or available through communication with the custodial parent, the participant, the State child support enforcement agency or the Issuing Agency, the NMSN may not be rejected. For example, an order may misstate the names of the participant or alternate recipients, and the plan administrator can clearly determine the correct names; or an order may omit the addresses of the participant or alternate recipients, and the plan administrator’s records include this information. In such instances, the plan administrator should supplement the NMSN with the appropriate identifying information, rather than rejecting the NMSN as not qualified.

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16. If a plan provides benefits solely through a Health Maintenance Organization (HMO) or other managed care organization with a geographically limited benefit area, is the plan required to create and provide comparable benefits to a child residing outside of the HMO’s service area?

No. A medical child support order is not qualified if it requires a plan to provide a type or form of benefit that is not otherwise available under the plan. Requiring a plan that provides benefits solely through a limited-area HMO to provide benefits to alternate recipients outside of the HMO’s service area (i.e., on a fee-for-service or any other basis) would be requiring the plan to provide a form of benefit that it does not ordinarily provide. On the other hand, if the child is able to travel to the HMO’s service area for medical care, the plan would be required to provide benefits to the child. [ERISA §609(a)(4)]

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17. Is the plan administrator required to enroll the child into the same coverage and option in which the participant is enrolled?

In accordance with ERISA, a child that receives coverage pursuant to a QMCSO is treated as a beneficiary under the plan. Therefore, the child is also treated as a dependent of the participant under the plan. If a QMCSO specifies that a child is to receive a particular level of coverage or option that is available under the plan, but the participant is not enrolled in that particular coverage or has not selected that particular option, the plan administrator may be required to change the participant’s enrollment to the extent necessary to provide the specified coverage to the child. [ERISA §609(a)(7)(A)]

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18. Who is obligated to pay employee contributions or premiums that the plan requires for coverage of a child named in a NMSN?

The participant in the group health plan is responsible for the payment of any costs associated with the provision of coverage. The NMSN provides that the named employee is liable for any employee contributions required under the plan for enrollment of each child named in the order. However, if Federal or State withholding limitations prevent withholding of the required employee contributions from the employee’s paycheck, the plan is not required to provide coverage to the child. The employer is required to use Part A–Notice to Withhold For Health Care Coverage to notify the Issuing Agency if such limitations prevent withholding of the required employee contributions. The employer may return the Notice to Withhold For Health Care Coverage and the Employer Response pages of Part A (first two pages) without the Instructions to Employer to the Issuing Agency.

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19. What must the employer do after the plan administrator has completed the enrollment process for the child(ren)?

Upon notification of the enrollment from the plan administrator, the employer must determine if the necessary employee contributions may be withheld from the employee’s wages without violating any applicable withholding limits. Part A of the NMSN contains information for the employer regarding Federal and State limitations on withholdings, any applicable withholding prioritization laws, and the duration of the withholding obligation. If withholding limits prevent the employer from withholding the employee contributions necessary for coverage, the employer must use the Employer Response on Part A to notify the Issuing Agency of its inability to withhold the necessary amounts. If the amounts necessary for coverage may be withheld, the employer must initiate such withholding and transmit the withheld amounts to the group health plan to pay for the child’s coverage.

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20. What must the plan administrator do in the event that the employer is unable to withhold from the participant’s paycheck the employee contributions necessary to provide coverage to the child?

If Federal or State withholding limitations prevent withholding from the participant’s paycheck the additional contribution required to provide coverage to the child(ren), the employer must notify the custodial parent and the Issuing Agency.Unless the employer is able to withhold the necessary contribution, the plan administrator is not required to extend coverage to the child. However, the custodial parent or DRS may be able to modify the amount of cash support to be provided in order to enable the employer to withhold the required contribution to the plan. The participant may also voluntarily consent to the withholding of an amount otherwise in excess of applicable withholding limitations.

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21. Does a child have any rights to continuation coverage?

According to the Internal Revenue Service, which has jurisdiction over such questions, a child covered by a group health plan pursuant to a QMCSO is a “qualified beneficiary” with the right to elect continuation coverage under the Federal law known as the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) whenever the plan is subject to COBRA and if the child loses coverage as a result of a qualifying event. [ERISA §§607(3) and 609(a)(7)(A)]

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22. When may the plan administrator disenroll a child?

A plan administrator may disenroll a child at the same time and under the same conditions as it can disenroll other dependents of participants under the plan. For instance, a plan administrator terminates coverage when the participant terminates employment and neither the participant nor the child elects COBRA continuation coverage. Therefore, the plan administrator may discontinue coverage for the child. Similarly, if the group health plan ceases to provide coverage for dependents that are over the age of 18, the coverage for a child who is over the age of 18 may be terminated if COBRA continuation coverage is not elected. The plan administrator may also disenroll a child upon receipt of written evidence that the court or administrative child support order is no longer in effect or the child is or will be enrolled in comparable coverage which will take effect no later than the effective date of disenrollment from the plan.

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