NATIONAL MEDICAL SUPPORT NOTICE - AN OCSS AND OKESC WEBINAR

Dorinda Morris: Our presenters today are: I’m Dorinda Morris. I’m the managing attorney for the Fairview Child Support Office and I’m also an attorney member of the Oklahoma Child Support Services Medical Support Consistent Excellence Team and my colleague today is Dayna Clark. Dayna, will you introduce yourself?

Dayna Clark: Hi, I’m Dayna Clark and I am one of the three supervisors here at Oklahoma Employer Services Center. Prior to opening this center, I spent eight years working for Child Support Services directly at the state office.

No Audio: RCH Credits from APA - contact joshkahoe@ou.edu.  Webinar - www.OKESC.org website later in 2012.
 
Ms. Morris: Okay, we’re going to start by describing what is the National Medical Support Notice. Can we go forward on that slide please? Okay, let me mention to you that you’re on the PowerPoint and we just passed the slide that did have Josh’s email address, you have a copy of your PowerPoints that he sent to you prior to beginning our webinar so if you need to refer back to that so that you can send him the email requesting your credit for this class, you may do so and you do have that address on your materials.

No Audio: What is the NMSN? - 1993 Amendment to ERISA. Requires Health Care Coverage to children without regard to residing with employee and without regard to wedlock. Coverage to children based on Medical Child Support Order

What is the National Medical Support Notice? The legal basis for the National Medical Support Notice, and we’ll be referring to it, since it has a rather long name, as ôNMSN.ö You’ll hear that term used as a generic term for this document that’s used nationwide. 

The authority for the NMSN was a 1993 amendment to ERISA, which stands for the Employee Retirement Income Security Act, a federal law. It requires employer-sponsored group health plans to extend healthcare coverage to the children when a parent employee is divorced, separated or never married and when they’ve been ordered to do so, to provide the medical support by state authorities. This may include the court or administrative agency that’s authorized to issue child support orders. Next.

Generally, a stakeholder agency may require an ERISA covered health plan to provide health benefit coverage to children by issuing a medical child support order. The group health plan must determine whether the medical child support order is qualified. And a Qualified Medical Child Support Order is also known as a "QMCSO" and that's a general term under ERISA for such an order.

The National Medical Support Notice, the NMSN, is a federally required document that is used by all state child support agencies. So it’s a national notice. It will be with differences possibly for formatting from one state to another. You should generally see that a NMSN is pretty much the same no matter what state child support agency it comes from. A NMSN is by definition a Qualified Medical Child Support Order if it is properly completed by the agency that sends it to you. 

The NMSN is sent to an employer when a parent or custodian has been ordered by the court to provide health insurance for a child and those NMSN’s that are properly completed, if they are determined by the employer and plan administrator to be qualified, they must be honored by all employees’ group health plans.

Well what is a medical child support order? Well a medical child support order is any kind of a judgment, decree or an order that is made pursuant to a domestic relations law of a particular state or other state laws relating to medical child support and it also has to provide for group or health benefit coverage for a child of a participant that’s eligible under a group plan and relates to benefits under that plan. And the authority for that is under ERISA. 

A QMCSO, a Qualified Medical Child Support Order, is a child support order that recognizes the right of an alternate recipient - that's the term of art under ERISA - recognizes the right of an alternate recipient who is really defined as the child to receive benefits for which the participant or beneficiary is eligible under a group health plan, or it assigns to an alternate recipient the right of the participant or beneficiary to receive benefits under the group plan. 

Now in plain speak, that means that, basically, the child has the same rights to participate in the plan that the participant employee does. It includes the rights to receive documents and plan descriptions that the employee would receive.

A QMCSO also is recognized by the group health plan as qualified because it includes information and meets other requirements of the QMCSO provisions of ERISA. Certain examples of the required provisions are... let’s go on. Oh, I’m sorry! Go back. Thank you. 

Okay we have to have the name and the address of the alternate recipient, this is typically the child. The order may substitute the name and mailing address of the agency. The substituted address may be used by the plan administrator. For example, the state may provide an alternate address for the state agency, an example where the custodial parent has indicated that family violence exists between the parties and the custodial parent may be afraid to have their address shared with the employee. 

In that case, we would designate the state’s address as the address that can be used and that is still acceptable under ERISA and it would still qualify as a Qualified Medical Child Support Order. There has to be a reasonable description of the type of coverage in which the order is asking the plan to enroll the child. 

There also has to be a period that the order applies to, it will have a beginning date. And the order may also not require a benefit that's not otherwise provided under the plan. For example, if the employer doesn't provide coverage to any of its employees, nothing in a QMCSO would make the employer be required to provide that coverage to a child just because there's a QMCSO. 

Similarly, if there’s no out-of-state coverage, they would not be required to find a policy that will be available to a child out of state if it doesn't provide those benefits to any employees. What state laws are enforced by QMCSO? First of all, there has to be a requirement that the child being enrolled, the child has to be able to access the coverage even if they were born out of wedlock, even if they don't reside with the parent who is the participant in the plan, even if they’re not claimed as a dependent on the employee’s federal tax return. 

At the time that the QMCSO provisions were added to ERISA, Congress also added section 1908 to the Social Security Act and that section requires that states can't receive federal Medicaid funds unless they have in place specific state laws relating to medical support and those laws include things like the requirement that I just described. 

Also it requires a health insurer to enroll a child even if it's not the proper enrollment time. So in other words, without regard to "open season enrollment." Most employers seem to be familiar with that and they are looking for a QMCSO in order to enroll a child in mid-year. 

State laws also must require employers and insurers to comply with the court or administrative order requiring the parents to provide health coverage for a child and the state law has to require insurers to permit the custodial parent to file claims on behalf of his or her child under the noncustodial parent’s health insurance.

As I indicated earlier, part of the alternate recipient’s rights is to access the health insurance in the same way that the employee participant would. The insurers must be able to send benefit payments to the custodial parent or health care provider and not just to the participant employee. 

In Oklahoma, the authorities that have been adopted that comply with this federal law are found in Title 43 Oklahoma statutes, section 118.2, that’s the section that relates to employers, and also Title 36 Oklahoma statutes section 6058A, which is the section that applies to insurers. 

Under these two laws, employers and insurance companies can be fined up to $200 per child per month if either of them fails to comply with the NMSNs, so it’s very important that employers understand and comply with a NMSN when they receive it. Dayna is going to talk to us a little bit more about the NMSN and what you can expect to receive.

Ms. Clark: One question that we receive quite often is how do the employers receive the National Medical Support Notice, what kind of triggers indicate that we need to send them? We receive matching information when people owe child support and orders for medical support we receive them from several different locations. 

The Oklahoma Employment Security Commission provides us with new hire information. We also receive that through the national database of new hires as well as quarterly wage reporting that comes from the federal government. And when those matches are populated into our system automatically, that the person’s employed by that company or that agent, whenever we receive those information and populates and verifies in our system, we’re required under the NMSN’s regulations that a National Medical Support Notice must be sent within two days of verifying employment for a non-custodial parent. 

Parents also call us as well, both custodial and non-custodial parents will call us and provide us with employment information and we will also populate that into our system which triggers documents to be sent.

What does the National Medical Support Notice look like? There’s actually four parts. Part A is the initial part which is the cover sheet that must be filled out by the child support agency. It provides the children’s names, their information, which of the coverage types are required to be enrolled in. And then there's a second part of it which is the employer response portion of part A, which is where the employers will determine whether or not they can proceed and process the document and turn it over to the plan administrator. 

Part B of the National Medical Support Notice also again contains the actual order information that requires the children to be enrolled and then the response portion of that which the plan administrator will then also send back to the child support agency. We’re going to look at that document in just a second. 

What should an employer do when they receive a National Medical Support Notice? There are several steps. First of all, is that person employed by the company? Is it a qualified order as per the description of what Dorinda explained needed to be in the document? Is the employee eligible for insurance? I mean are they not probationary or have they worked enough hours depending on how your company administers that? Is the cost of coverage reasonable? And if so, then it needs to be forwarded to the plan administrators.

So we are now going to look at the National Medical Support Notice and kind of go step by step into the specific areas to give you more detail. So the first part is where this is the part that has to be filled out correctly by the child support agency. And this is where we include the employer information that we have. Scroll down a little bit. Sorry, we are having a little bit of technical difficulties. There we go. 

This is also where the address, the mailing address for the custodial person is going to be listed as well as the children's names, their date of birth and their social security numbers. And right below that section is the types of coverage that are required for any employers to enroll in if available through the company.

The second part is where it begins the employer response. If the employee is not employed by and never has been employed by the company, that will be option number one. Option number two is that the employers do not maintain insurance for any of their employees. Option number three is employees that may work for you that wouldn’t qualify for insurance, so it’s just part-time employees. They’re usually not offered medical benefits. 

Option number four is that the employee has been terminated through the company so they’re no longer employed. And option number five is that they exceed the withholding limitations. So if any of those apply and they're not going to be enrolled, planners are required to select the option, sign and date that and send it back to us. 

We are going to go a little bit more over the limitations. Go ahead onto the next page. On the next page, which is usually page five, sometimes the printing will throw off so we don't like to say this is page five because it may actually showing up on another page, is where they talk about the limitations of withholding. 

Something that has changed within the last two years within child support that's not necessarily always known is that there has now been changes to the law that limits the amount of the insurance cost to 5%, only on cases where there is a new order or an order has been modified. 

So this is the page that shows the withholding limitations if the order has been entered in and that is part of what actually employers need to consider. So on this limitations withholding section, the law in Oklahoma is 5%. So if there is an adjustment to the order, it will say "5%" in that first line and it will actually give you a dollar figure amount of what the benefit cannot exceed on the line number three. 

This is not something that employers are expected to calculate. Child Support should have that done already for you. So if there is no percentage and no dollar figure amount, it means that the order has not actually been modified to include that language and would then just go back to following the CCPA limits. 

So if everything is good, the employer sends back Part A telling us that "Yes, they qualify" and they forwarded it on to the plan administrator, and they’re supposed to provide us with the plan administrator's contact information, which is actually at the bottom of this page right here, two pages after the response. 

Once the employer does that, they are then to send Part B to the plan administrator for them to finish the process by actually enrolling the children in the plan itself. So the first page of part B also includes the same information as far as the order, what was ordered, when was it ordered, same information that the employer had: the children’s names, social security numbers and the type of coverage. 

And then the plan administrator needs to make a second determination on whether or not they're able to go ahead and enroll the children. They’re supposed to let us know the date that they received it, because there is a time limit - the employer and plan administrator combined have 40 days to complete and return the document to the child support agency. So when it was determined to be qualified by the employer is option number one. 

Number two tells us what they're going to do. Are they enrolled? Or B, is there more than one type of coverage that needs to be chosen? Sometimes employers will have multiple plans and they need somebody to make that decision instead of them doing it themselves and they send that to us. 

Whether or not they're eligible. So if they are on a waiting period, sometimes they have to wait a certain amount of hours or a certain number of days to be qualified for a company’s insurance. We need to know that so that we know that the order was received and that we’re going to expect to wait for information for whenever that period of time is, so that we know that the employers are in compliance.

One thing we like to stress at this point too, is if they do have a waiting period, they are expected to go ahead and enroll after that waiting period has ended. They are not to expect another document telling them to do it a second time because this is the actual order that requires them to make that enrollment.

And if it is not a qualified order, the number five is the response that they can send back to us telling us why it is not a qualified order and why they have not enrolled the children. Of course then it has the contact information for the plan administrator. 

And the rest of that is just basically instructions. Of course we are here to help employers with anything they have. Any questions they have, any issues they have by calling us during our normal operating hours. We are open Monday through Friday, 8am to 5pm.I believe that leaves us open to questions. Oh, I’m sorry. We're going to show you one other companion document. 

This document is a medical questionnaire that is sent to employers. We are trying to combine these two documents but all states are actually only limited to certain things they can change on the NMSN. There are certain fields that each state can change depending on what their state laws are. 

But in general we can’t change the form as Dorinda mentioned. It should pretty much look the same from state to state. So there’s a big piece of information missing, and that is what type of insurance actually has been chosen for the child. 

So this is a secondary document that you should also receive in conjunction with the National Medical Support Notice, and request that information. Go down...It requests the insurance, you know, who is the carrier, what is the policy number, who’s covered by the insurance, including their social security numbers, what types of coverage, things of that nature. 

We will hope that this still works correctly and that they come relatively close. They should be printed within the same day, but you probably will receive them in separate envelopes. 

But we do need all of the information so that we can input that into the system to show that the party who’s been ordered is in compliance with that order, which also then lends itself to the company being in compliance with responding to the order. So it’s vital that we receive all of that information so that it can also be sent on to the custodial parent if necessary. 

Ms. Morris: Okay, we’ve got one question that has been submitted, and this is one that actually gets asked quite often. Let me pull it up here so I can read it. Okay. "The National Medical Support Notice provides the reasonable cost of coverage as $195 a month. Do I apply that number against the entire cost of coverage for the family, or just part of it?ö

Well, that question and varying versions comes up pretty often. The first thing you have to do is to look at what the out-of-pocket cost is for the employee. If the employer pays a portion of the insurance premium, if they pay a benefit allowance in other words, that amount is deducted from the total premium to arrive at the amount that the employee pays. 

Oklahoma statutes do not provide a formula for employers to use for this purpose, but they do provide a formula for the court to use in determining whether a medical support premium is reasonable in cost. It’s considered reasonable if it doesn't exceed 5% of the employee’s income at the time the order is being entered. 

But Child Support Services is urging employers to use the same formula the courts do to determine whether the insurance is reasonable in cost. The reason we suggest that is because the employee has an obligation to provide insurance if the court has ordered them to do it and the court’s going to order it based on this formula. 

The obligor’s going to be under an obligation to provide the insurance if the court has ordered it whether or not the employer assists in the enrollment. What the employer can assist with is enrolling out of season for the child and allowing the employee to comply with the court order. 

This is the way the formula would work under the court order. If the court’s looking to see whether the insurance is reasonable in cost, let’s use a simple example first: The employer pays 100% of the employee cost and let's suppose that there is one child listed on the NMSN and there's no other children for this particular employee. 

If the cost to enroll the child is $195 or less, in my example, then the employers able to enroll the child. And if it is more than that than the cost is not reasonable, the employer completes the part A response to the NMSN and advises that they're not able to enroll child.

Okay, let’s take another example. Example two, the employer pays 100% of the employee cost again. And let’s suppose the employee already has two children in his household covered.And the NMSN includes two additional children. The total cost for the children would be divided by four children and then multiplied by the two children on this case. 

Or to put it another way, the total cost premium cost for the children would be divided in half. If the total cost let’s say, let’s put some dollars to my example, if the total cost for the children is $380 for four children, the portion for two of those four children would be $190.

And since that's less than $195, the children can be enrolled. If the numbers were different and that it was more than $195 obviously they couldn’t be. Okay, an alternate way to look at this example would be to determine whether there's any additional cost for adding these other two children. 

Sometimes the court will order even if the cost, if we use the formula, the court might look at the total cost for all four children and determine it doesn't cost this employee anything to add these two extra children. The premium is the same if you have any more than two children, you know, on a particular policy. 

If that is the case, and if the total cost to add two extra children is $0, then another way to look at it would be that you could add the children because it does not increase the cost for that particular employee to add those two additional children. 

Okay, let’s look at a third example. We’re getting increasingly more complex. If the employee is eligible for enrollment but they’ve chosen not to enroll in any of the insurance plans then the employer receives a NMSN and there’s one child included in order to enroll that child, if the employer has a plan that requires the employee to be enrolled if there are any dependents enrolled then it would be necessary to enroll both the employee and the child and that's permissible under a Qualified Medical Child Support Order. 

To determine the reasonable cost, you’d take the total premium cost for the employee plus one child, minus the cost for the employee only and whatever the remaining amount is, is the cost for the child. Okay, let’s look at some numbers if you want jot these down as I go along. 

Suppose that it costs $700 for premiums for an employee and one child. And the cost for the employee only would be $550. If that’s the cost, then the remainder is $150. That would be the attributable cost for one child and this child could be enrolled. 

If you can’t determine in your particular situation how the calculation applies in your case, call the Employer Services Center. We have trained representatives there that are here to help you. Okay, I think we have some additional questions that have come up on the chat. And I believe Dayna’s been monitoring those. Can you help us? 

Ms. Clark: Okay. Let me scroll back a little bit. Some of them, you know part of the beginning of the chat unfortunately some people were having problems with the sound. Okay.

One of the questions... and Barbara Perkins is actually on our chat as well. She is our liaison between Child Support and is attempting to answer questions as well and I would like to go ahead and just speak to some of the things that were asked. One of the questions that was asked was if there is no dollar amount in that section about the withholding limitations what do you do? And that is that you adhere to the CCPA, the Consumer Credit Protection Act limitations on how much money can be deducted from an employee’s paycheck which should be applied anyway when deducting child support as well. 

So it follows that same line with medical insurance if the amount has not already been determined by the courts at the 5% because we are the ones to determine the amount, not the employers. Another question that was asked was why do you get the forms so often? Some employers unfortunately received multiple copies of documents asking for information. 

Part of it is that they're not all the same documents. There is one document that is a form that we consider to be an employer locate form. Whenever employment information is provided to us through the multiple areas, unless we know from an employer in fact that the employee is employed by them, there’s an initial document that looks very similar to the medical request document that asks questions like: are they employed? What are their salaries? Is the insurance available? How much is the insurance costs? 

And that section looks very, very similar to the medical questionnaire portion of it. Part of what we do here is that we are trying to stop multiple documents from going to employers. But if we don’t receive a response within the designated time frame, we have a response, I believe it’s 45 days for a medical response, the system will automatically regenerate documents and send them out. 

Sometimes it’s a system problem. Sometimes the employer will actually be on the case twice. It will be added by a caseworker and then get added again by one of our means of populating the information. So if you continue to receive multiple documents it may indicate that there may be something wrong, something that we need to look at. 

And we do encourage everybody to call ESC to let us know that so we could try to take a look and see why you are receiving multiple documents because you shouldn't receive them more than once. The only exception to that is that once an employee has been enrolled in insurance, every year towards what your normal enrollment periods are, you will receive a document. The same document that requests the information for medical insurance to ensure that they are still enrolled in insurance. 

So you should typically see a request every year as a reminder or a request to refresh your information, but they shouldn’t continue to send them on the same document on the same person repeatedly. So that’s something that we will definitely need to know. Just a moment and I’ll see...

Ms. Morris: I think I found one.
 
Ms. Clark: Okay.
 
Ms. Morris: And I wanted to clarify this, too. We have one person that wanted to know, if the limit for withholding for children's coverage is left blank, are there any limitations regarding the costs that the employee pay? Okay. Can you pull up the NMSN again? 

We are going to let our technical assistant pull up that form because I want to show you something on it. Okay well we won’t be able to get back to that maybe... Oh, the share part. Yeah, there we go. 

Well, let me talk while he’s trying to pull that up. The portion of the limitation of withholding that Dayna showed you, it normally on our forms usually will have 50% in there. The language that’s usually on that section of the form where it’s looking for a percentage... oh, thank you. Can you get back up to the limitations of withholding part?

That normally will have on this form, there’s a blank there but normally... okay and let me see if I can highlight for you what we’re looking at. Nope. Ah. I’ll just... okay where it says limitations of withholding there on the next page.

Okay. There is on the top line on under the limitations of withholding it says a percent of the employee’s aggregate disposable weekly earnings. What is normally put in that blank is either 50%, those are the CCPA limits. Or 55%, 60% or 65%. 

What those refer to under the Consumer Credit Protection Act is either 50% of the disposable earnings of the employee if they don't have other dependents or arrearages of more than 90 days. It’s 55% if they have other dependents and arrears of more than 90 days. If they don't have other dependents it’s 60% or 65%. Those are usually the percentages. 

The employer is going to know whether this employee is claiming if they have other dependents. So you’ll know whether it's at 50% or 60%. That's what we’re looking at now is the PowerPoint that reminds, you do have this in your materials, and this does show you what those percentages mean. You're going to know whether your employee is claiming that they have other dependents. 

What you don't know is whether they have arrearages. If we don't tell you that, then you would use the 50% or 60% limitation. If, on the form, under limitations of withholding, if there is a dollar amount on paragraph three, where it says the amounts allowed for health insurance premiums by the child support orders as indicated here, there will be a dollar amount there if the court has indicated a dollar limitation.

In Oklahoma, the law that limited the amount of the reasonable cost limitation didn't begin until 2009. There are many, many orders still being enforced that did not have those limitations. So if it's blank, then what you would limit it to is either what the percentage is in the very first paragraph and if that paragraph is blank, you would use 50%.

Let’s look back at our chat and see if we have any additional questions that we haven't addressed. There are a number, as you can see. Those of you that are looking at the chat, there are a number of technical issues. 

Okay, generally when you have a presentation like this, you are looking at having possibly three things that you may remember from the presentation of all the things that are mentioned and these are the three things we'd like to take away from this presentation: 

One, remember that the National Medical Support Notice is an order. It's not a suggestion. It's not a request. It’s not something that the employee can ask you to disregard. If you do, the employer and possibly the plan administrator can incur some penalties and we don’t want that to happen. So remember that the NMSN is an order, it summarizes what the court has ordered and it’s a requirement. 

Second, only apply the reasonable cost of coverage if the NMSN specifically gives you a dollar amount to do so under that limitation of withholding paragraph we just looked at. If your employee suggests to you that he has had a recent hearing and he's only supposed to get insurance if it doesn't cost more than 5%, if you see nothing on that form and you have reason to believe that there's something missing, call the ESC. Don't work with the district child support office to confirm whether there has in fact been something omitted from the NMSN. However in the meantime, you should go ahead and enroll. 

The third thing we want you to remember is that ESC is here to help you.We’ve got trained representatives whose job it is to make sure that we are available to answer your questions, to keep you as much as possible from having to wait in a long queue for a customer service rep. Okay. 

There was a request that we send out additional copies of the slides that have been presented. Those were sent ahead of time but if there... Josh is capturing the names of all the people that have signed on and I believe he is going to plan on sending those out. 

We also will send you some other materials including a bibliography that has some resource information. We’ve mentioned to you several times some resources that you can use to help you answer questions. 

No Audio: NMSN Webinar contact information:  Oklahoma Employer Services Center.  Phone: 1-866-553-2368.  Email: OCSS.Contact.ESC@OKDHS.org. Fax: 1-405-325-8210 

You’ll see on your screen now the contact information for the Employer Services Center. You have their phone number, you can reach them by email and you can reach them by fax. They will be happy to talk to you during business hours and contact you if they need to return an e-mail, they'll do that as well.

Toby Hallows: One other thing that we would like you to do, you should be receiving a survey that will go out by email from Josh. Please fill that out and return that. The last webinar we did, we had about seven or eight return. 

Please, it will take I believe, only 3-4 minutes to do. The purpose of it is for us to really get these webinars down into a science that will provide a better experience for you as the viewer and for the classroom type of setting - whether or not we need to modify the presentation styles, the presentations themselves, so forth and so on. 

So please when you receive that survey from Josh, please fill that out and return that. It is critical to how we are going to produce these in the future, because we are going to have future webinars. Thank you. 

Ms. Morris: Alright, we appreciate... we don’t see any additional questions that have come in and a number of, let’s see, we do have one possibly coming in. If you are thinking, we do still have more time. So if you are thinking of some questions and if you haven't yet written them down, feel free to do that now. 

Remember, you can also write up your questions and send them to the Employer Services Center. The next webinar is in August and we will address the electronic income withholding order, Barb is reminding us. So do watch for that. We hope that the technical difficulties that several of you have described will be resolved by then. And when we see your comments, we’ll know what things you'd like us to work on. Thank you very much for inviting us into your workplace. We thank you for your participation and we'll see you next time.