National Medical Support Notice
Frequently Asked Questions

The National Medical Support Notice (NMSN) is designed to assist employers with helping the children of their employees receive health care plan coverage. State law requires Missouri's Child Support Enforcement (CSE) to begin issuing this federal form to employers on August 28, 2002. The NMSN, required by the federal Child Support Performance and Incentive Act of 1998, was developed by the federal Departments of Labor and Health and Human Services with input from representatives from the business and employer communities.

The following is a list of questions and answers that may assist employers in better understanding the NMSN. Employers and plan administrators are encouraged to consult with their own attorneys. (Note: Slight variations in responses may be experienced with the NMSN issued by states other than Missouri.)

1. Is the requirement for employers to enroll children in health care coverage based on a notice from Child Support Enforcement a new requirement?
   No. Most employers are already familiar with notices that require them to withhold premiums from employees when a parent is ordered to provide health care coverage for his or her child(ren). The National Medical Support Notice is a new, federally-required form that serves the same purpose. The form was designed in consultation with a federal workgroup that included representatives of major employers, payroll associations, insurance administrators and government representatives. Their intent was to provide employers with a standardized set of forms, processes and timeframes - something employers had requested.
2. Do employers have to complete a form for every employee who pays child support?
   No. Employers must process and respond to the National Medical Support Notice (NMSN) only if the employer receives an NMSN for a particular employee. Child Support Enforcement or other state child support enforcement agency may issue these notices to employers for their new employees and for current employees with new or modified child support orders.
3. Does Child Support Enforcement (CSE) notify the employee about the withholding for health care coverage premiums?
   CSE sends a copy of the National Medical Support Notice to the employee by first-class mail.
4. The employee refuses to complete the paperwork required to enroll his/her child in the health care plan. What should the employer or plan administrator do?
   The plan administrator must forward the health care plan paperwork to the custodial parent. The plan administrator or employer may also submit the documents to Child Support Enforcement, which is also authorized to complete the documents.
5. An employer offers health care plan coverage through three different providers. The employee wants the child(ren) enrolled in the same plan in which s/he is enrolled. Does the other parent have a right to choose another health plan?
   If the employee is already enrolled in a health care plan, the child(ren) must be enrolled in the plan in which the employee is enrolled.
6. May the employer charge a fee to the employee or the child support enforcement agency for processing the National Medical Support Notice (NMSN) and withholding the income?
   No. Charging a fee is not permitted for processing the NMSN and/or sending a health care plan premium payment to the plan administrator.
7. Group health care plans as defined in the Employee Retirement Income Security Act of 1974 (ERISA), Section 607(1), are required to provide benefits in accordance with the applicable requirements of any Qualified Medical Child Support Order (QMCSO). Is the National Medical Support Notice (NMSN) a QMCSO?
   Yes, the NMSM meets the requirements for a QMCSO if the child support agency correctly completes it and if coverage for the children is or will become available. The plan administrator of a group health care plan must treat the NMSN as a QMCSO under section 609(a)(5)(c) of ERISA.
8. What are the prioritizations that affect withholding for health care coverage?
   In Missouri, an order of income withholding for health care coverage, child support and/or spousal support has priority over all other legal processes or withholdings against money, income or periodic earnings of the noncustodial parent (this includes payroll deductions for deferred compensation, savings plans and credit union payments). In Missouri the withholding priority sequence is current child support, then children's health care plan premiums, then current spousal support, then payments to be applied to past-due support. (This may vary in other states.) NOTE: Federal tax levies in effect before receipt of a child support income withholding notice have priority unless the Internal Revenue Service agrees to an alternative priority. The National Medical Support Notice provides the limits on withholding for the particular employee in Part A, "Limitations on Withholding."
9. Are there limits on how much an employer can withhold for cash and medical support?

   Yes. As stated in the National Medical Support Notice (NMSN) Part A, "Limitations on Withholding," the employer may not withhold under the NMSN more than the lesser of:

   1. The amounts allowed by the federal Consumer Credit Protection Act (15 U.S.C. 1673(b));
      
   2. The amounts allowed by the laws of the state of the employee's principal place of employment; or
      
   3. The amounts allowed for health insurance premiums by the support order, if applicable, as stated in the NMSN for the specific employee.
      

   The federal limit applies to the aggregate disposable weekly earnings (ADWE). The ADWE is the net income after mandatory deductions, including: state, federal and local taxes; Social Security taxes; and Medicare taxes.
   Withholding limits - depending on the type of support order and the state issuing it - can amount to as much as 65 percent of the employee's ADWE. The order will provide instructions on the maximum percentage you can withhold.
   By policy, Missouri Child Support Enforcement always caps the withholding at 50 percent of the employee's ADWE.
   View Withholding Examples

10. An employee's National Medical Support Notice (NMSN) instructs the employer to enroll the child in medical and dental coverage. The withholding limit will only allow the employer to enroll the child in one of these coverages, not both. What should the employer do?
    The employer should contact the child support enforcement agency listed on the NMSN for direction.
11. The plan administrator has enrolled the child(ren), and the employer is withholding premiums. What does the employer do if the insurance plan in which the child is enrolled is no longer available to the employees?
    If there is a change in insurance plans available, the National Medical Support Notice remains in effect. The employer and the plan administrator must take action to ensure the child(ren) is enrolled in a new available insurance option.
12. The plan administrator has enrolled the child(ren), and the employer is withholding premiums. What does the employer do if family coverage is no longer available?
    If family coverage is no longer available to all employees, Child Support Enforcement suggests that the employer notify the child support enforcement agency that issued the National Medical Support Notice.
13. The plan administrator has enrolled the child(ren), and the employer is withholding premiums. What does the employer do if the employee quits or is laid off for a long term?
    The employer must notify the child support enforcement agency (listed in upper-left corner of the National Medical Support Notice). This notification may be a copy of any notice the employer is required to provide under the continuation-of-coverage provisions of the Employee Retirement Income Security Act of 1974 (ERISA) or the Health Insurance Portability and Accountability Act. On the copy sent to the child support enforcement agency, the employer should write the case number, support order number or the employee's Social Security number. The employer may also complete Item 3 of Part A, Employer Response, to report this information to the agency.
14. Although the employer has notified Child Support Enforcement (CSE) that no health care plan coverage is offered to employees, s/he continues to receive National Medical Support Notices (NMSNs) on new employees. Why do the NMSNs continue to be sent?
    The NMSN requires the employer to respond when health care plan coverage is not available. The employer needs to complete and return the response (Part A) regardless of whether s/he has notified CSE in the past that health care plan coverage is not available. Eventually, CSE hopes to prevent the generation of NMSNs in this situation. Until then, CSE thanks employers for their patience and cooperation.
15. Who may the employer contact with questions about the National Medical Support Notice (NMSN)?
    Employers may contact the child support enforcement agency listed on the NMSN (Part A, Page 1, upper left corner). For Missouri withholding questions or questions that are not case-specific, Child Support Enforcement also provides a toll-free employer information line: 1-800-585-9234.