Fillable NATIONAL MEDICAL SUPPORT NOTICE - PART A NOTICE (U.S. Department of Health & Human Services)

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NATIONAL MEDICAL SUPPORT NOTICE - PART A NOTICE (U.S. Department of Health & Human Services)

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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:
Notice Date:
CSE Agency Case Identifier:
Telephone Number:
FAX Number:
Court or Administrative Authority:
Order Date:
Order Identifier:
Document Tracking Identifier:
Employer web site:
See NMSN Instructions:
http://www.acf.hhs.gov/programs/css/resource/national
-
medical-support-notice-form
Employer/Withholder’s Federal EIN Number
Employer/Withholder’s Name
Employer / Withholder’s Address
Custodial Parent’s Name (Last, First, MI)
Custodial Parent’s Mailing Address
Child(ren)’s Mailing Address (if different from
Custodial Parent’s)
Name and Telephone of a Representative of the
Child(ren)
C
hild(ren)’s Name(s)
Gender DOB SSN
R
E:
Employee’s Name (Last, First, MI)
Employee’s Social Security Number
Employee’s Mailing Address
Substituted Official/Agency Name
Substituted Official/Agency Address
Required if Custodial Parent’s mailing address is left blank)
Mailing Address of a Representative of the Child(ren)
C
hild(ren)’s Name(s)
Gender DOB SSN
T
he order requires the child(ren) to be enrolled in all health coverages available; or only the following coverage(s):
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: 10/31/2022.
NMSN – Part A Page 1 of 5
_________________________________________________________________________________________________________________
_________________________________
_________________________________
_________________________________
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:
C
hild(ren)’s Name(s) (Last, First, Middle
DOB
NMSN – Part A Page 2 of 5
___________________________________________________________
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. Empl
oyer forwarded Part B to Plan Administrator on
.
MM/DD
/YY
CONTACT FOR QUESTIONS
Plan
Administrator Name:
FAX
Number:
Contact Person:
Empl
oyer Name:
Employer Representative Name/Title:
Empl
oyee Name:
NMSN – Part A
Telephone Number:
Telepho
ne Number:
Federal EIN:
(if not provided on Page 1 of this Notice)
Date:
Page 3 of 5
NMSN – Part A Page 4 of 5
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 doc
ument 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.
EMPL
OYER 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:
a. 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
b. 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.
c. 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.
3. 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.
NMSN – Part A Page 5 of 5
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:
a. The court or administrative child support order referred to in this Notice is no longer in
effect; or
b. 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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NATIONAL MEDICAL SUPPORT NOTICE - PART A NOTICE (U.S. Department of Health & Human Services)

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Completed 7 July 2022

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