Do not provide a copy of the NMSN to the employee. The notice contains confidential information, including the child’s Social Security number and the child’s and custodial parent’s (CP’s) location information.
1. Purpose of the National Medical Support Notice
The National Medical Support Notice (NMSN) is issued when a child support order requires a parent to provide health insurance for the child(ren) through employment when coverage is available, accessible, and within the applicable reasonable cost limits.
NMSN includes Part A and Part B. Employers, and plan administrators must review the notice, determine eligibility, and process enrollment as required.
2. Employer Does Not Offer Insurance or Dependent Coverage
If the employer does not offer health insurance, does not offer dependent coverage, or the employee is no longer employed or is ineligible for coverage:
- Select the appropriate response on Part A of the NMSN.
- Return the completed response using the mailing address, fax number, or email address provided on the form.
3. Employee Is in a Waiting Period
Determine the remaining waiting period as of the date the plan administrator receives Part B.
Waiting period of 90 days or less
- The plan administrator qualifies the notice and waits until the waiting period expires.
- Once the employee becomes eligible, the plan administrator processes enrollment and notifies the employer if wage withholding is needed for the coverage.
- After enrollment, the completed MED5 must be returned, and the insurance cards must be forwarded to the CP as required by the applicable process.
Waiting period greater than 90 days, or measured by another method
- The plan administrator informs the employer of the waiting period.
- The plan administrator waits for confirmation that the employee has satisfied the waiting period.
- Part B must be completed and returned with the eligibility date indicated.
- Enrollment should be initiated when the employee becomes eligible.
4. Determine Whether Coverage Is Accessible
NMSN provides the address information needed to evaluate whether the child(ren) can access the insurance provider.
In most cases, coverage is considered accessible when the child lives within 60 miles, one way of the provider.
Review the available information to determine whether the plan meets the accessibility requirement.
5. Determine Whether Coverage Is Within the Reasonable Cost Limit (RCL)
Review the child support order and determine whether the cost of coverage falls within the applicable limits.
Coverage requirements
The plan must qualify as appropriate medical coverage under the applicable order and requirements. Review the plan information to determine whether the offered coverage meets those requirements.
Reasonable Cost Limit (RCL)
Review the limitations of withholding section of the child support order.
- If an RCL is specified: Use the dollar amount listed in the order. If the monthly cost to cover the child(ren) exceeds that amount, enrollment is not required under that cost limit.
- If no RCL is specified: Apply the applicable Consumer Credit Protection Act (CCPA) limits. Consider the child support withholding amount and the additional cost of the child(ren)’s coverage when determining whether the limits are exceeded.
If the cost exceeds the applicable RCL or CCPA limit:
- Select the appropriate response on NMSN.
- Return the completed form using the contact information provided on the form.
Important: If the medical coverage cost exceeds the applicable limit, enrollment in another type of coverage, such as dental or vision only, is not required under this guidance. Dental or vision coverage may be added to medical coverage only when the combined cost remains within the applicable limit.
6. Employee Is Not Currently Enrolled in Insurance
If the employee must be enrolled in the employer’s plan before the child(ren) can be added, the employee may also need to be enrolled.
The employee and child(ren) should be enrolled when required and when the coverage meets the applicable accessibility and cost requirements.
7. Enrollment Outside the Open Enrollment Period
Enrollment under an NMSN is processed as a qualifying event when applicable. It is not necessarily limited to the employer’s annual open enrollment period.
The employer and plan administrator should follow the applicable NMSN requirements and plan procedures.
8. Calculate the Cost of Coverage for the Child(ren)
When the employee must be enrolled to cover the child(ren), determine the additional cost attributable to the child(ren).
Example:
- Employee-only coverage: $50 per month
- Employee coverage plus child(ren): $200 per month
- Additional cost attributable to the child(ren): $150 per month
Use the additional cost of the child(ren)’s coverage when evaluating the applicable reasonable cost limits.
9. Employer Offers Multiple Insurance Plans
The employer should select an available plan that meets the applicable requirements for accessibility and cost.
Review the plan options and determine which qualifying plan can provide the required coverage within the applicable limits.
10. Only Dental and Vision Coverage Are Available Within the Cost Limit
If medical coverage cannot be obtained for any reason, do not require dental or vision coverage alone under this guidance.
Dental and vision coverage should be considered in conjunction with medical coverage when the combined cost remains within the applicable limits.
11. Employee Reports That the Child(ren) Have Other Insurance
The employee may report that the child(ren) already have other coverage, such as tribal coverage, coverage through a spouse, or private insurance.
When this occurs:
- Request proof of the alternate coverage.
- Send the documentation to the Employer Services Center (ESC) so the case information can be updated and the appropriate office notified.
- The office will determine whether the alternate coverage satisfies the applicable requirements.
- If the coverage is determined to be adequate, documentation will be sent to the office.
Continue following the existing order unless otherwise notified. Do not discontinue the insurance requirement based solely on the employee’s statement that other coverage exists.
12. Determine When Insurance Coverage Begins
The effective date of coverage depends on the insurance carrier’s requirements.
Coverage may begin:
- On the first day of the current month.
- On the first day of the following month.
- On another date established by the insurance carrier.
Confirm the effective date with the employer or plan administrator when needed.
13. Employee Can Be Enrolled Now
When the employee and child(ren) can be enrolled:
- Complete Part B of the MED5 as applicable.
- Complete the supplemental section with all required insurance plan information.
- Request insurance cards for the child(ren) from the carrier.
- Forward the cards to ESC when the NCP is providing coverage, so they can be forwarded to the appropriate party under the established process.
Ensure the required forms and insurance information are complete.
14. Employee Is Temporary, Seasonal, or Has Inconsistent Wages
If the employee is temporary, seasonal, or does not have consistent wages, evaluate whether the employee is eligible for coverage under the employer’s plan.
Under this guidance, an employee who cannot provide consistent and reliable coverage may be considered ineligible. Confirm the employee’s actual eligibility with the employer or plan administrator before making the determination.
15. Employee Is Already Paying Cash Medical
Do not stop the existing cash medical withholding solely because the employee has been enrolled in insurance.
The process is as follows:
- Obtain proof of insurance enrollment.
- Ensure the case is updated.
- Allow the process to proceed for termination of the additional cash medical obligation, as appropriate.
- Continue withholding the existing amount until the amended Income Withholding Order (IWO) is received.
- Once the amended IWO is received, follow the updated withholding instructions.
16. Employee Cannot Be Enrolled in Insurance
NMSN addresses medical insurance coverage. It does not independently authorize additional cash medical withholding.
If an additional amount must be withheld from the employee’s wages, an amended IWO will be issued as appropriate. Follow the existing withholding instructions until the amended IWO is received.
17. Employee Is the Custodial Parent (CP)
A National Medical Support Notice may be sent to the employer of the CP when the court order requires the custodial parent to provide health insurance for the child(ren).
Review the notice and process it according to the order and applicable requirements. Do not assume that the NMSN applies only to a noncustodial parent (NCP).
18. Child Is Covered by Sooner Care
The employee may state that the child(ren) already have Sooner Care and does not need employer-sponsored insurance.
The existence of Sooner Care does not, by itself, remove the employer’s and plan administrator’s obligation to comply with a valid NMSN.
Continue processing the notice according to the applicable requirements unless the responsible authority provides different instructions.
Case Worker Reminders
- Protect confidential information. Do not give the employee a copy of the NMSN.
- Review the child support order for the medical support requirement and any specified RCL.
- Evaluate eligibility, accessibility, and cost before determining the appropriate enrollment outcome.
- Ensure the correct MED5/MED5C sections and supplemental information are completed.
- Send proof of alternate coverage to ESC for case updating and office notification.
- Do not discontinue existing cash medical withholding until the amended IWO is received.
- Follow the existing order unless officially notified of a change.