Qualified Medical Child 

Support Orders

U.S. Department of Labor 

Employee Benefits Security Administration
 

This publication has been developed by the U.S. Department of 

Labor, Employee Benefits Security Administration.

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This booklet constitutes a small entity compliance guide for purposes 

of the Small Business Regulatory Enforcement Fairness Act of 1996.
Qualified Medical Child 

Support Orders

U.S. Department of Labor 

Employee Benefits Security Administration

 

 

Introduction 

A 1993 amendment to the Employee Retirement Income Security Act (ERISA) requires 

employment-based group health plans to extend health care coverage to the children of a 

parent-employee who is divorced, separated, or never married when ordered to do so by 

state authorities. This compliance assistance guide explains these ERISA provisions and 

describes how a plan can be required to cover a child.

Generally, a state court or agency may require an ERISA-covered health plan to provide 

health benefits coverage to children by issuing a medical child support order. The group 

health plan must determine whether the medical child support order is “qualified.” Such 

an order is referred to as a Qualified Medical Child Support Order (QMCSO). In addition, 

a state child support enforcement agency may obtain group health coverage for a child 

by issuing a National Medical Support Notice that the group health plan determines to be 

qualified.

Group health plan sponsors and administrators will find the information in this booklet 

useful in understanding the rights and obligations of those involved in child support

proceedings and those responsible for administering group health plans.1

The first section of this booklet provides general questions and answers about Qualified 

Medical Child Support Orders. The second section answers questions about National

Medical Support Notices and the role of state child support enforcement agencies in

obtaining health care coverage on behalf of children.Afinal resource section lists additional

resources that may provide useful information about ERISA and obtaining health care 

coverage and medical care for children.

1

As used in this booklet, the term “group health plan” refers to that term as defined in section 607(1) of ERISA and means 

generally any welfare plan established or maintained by an employer or employee organization (or both) that provides 

medical care to employees or their dependents directly or through insurance, reimbursement, or otherwise.

1

Section 1 

This section includes an overview of the ERISA provisions that require group health 

plans to extend health care coverage to children of eligible participants and beneficiaries, 

plus general information about the requirements that apply to a Qualified Medical Child 

Support Order (QMCSO). Questions addressed in this section: 

q What is a QMCSO?

q Who can be covered by a QMCSO?

q What information is required for a medical child support order to be qualified?

q Who determines whether a medical child support order is qualified?

q What types of health plans are required to recognize QMCSOs?

3
Q1-1: What types of plans are subject to the QMCSO provisions? 

The QMCSO provisions apply to “group health plans” subject to the

Employee Retirement Income Security Act of 1974 (ERISA). For this 

purpose, a “group health plan” generally is a plan that both:

m Is sponsored by an employer or employee organization (or both) and 

provides “medical care” to employees, former employees, or their

families.

m “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.

m ERISA does not generally 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, provisions of the Child Support Performance and Incentive 

Act (CSPIA) of 1998 require church plans to comply with QMCSOs 

and National Medical Support Notices, and state and local government

plans to comply with National Medical Support Notices.

[ERISA §§ 4(b), 609(a) and 607(1), Internal Revenue Code 

§ 213(d), CSPIA § 401(f)]

Q1-2: What is a QMCSO? 

A QMCSO is a medical child support order that:

m Creates or recognizes the right of an alternate recipient to receive 

benefits for which a participant or beneficiary is eligible under a 

group health plan or assigns to an alternate recipient the right of a 

4
 

participant or beneficiary to receive benefits under a group health 

plan; and

m Is recognized by the group health plan as “qualified” because it 

includes information and meets other requirements of the QMCSO 

provisions (see Qs 1–6 and 1-7).

In addition, a properly completed National Medical Support Notice 

(see Section 2) must be treated as a QMCSO.

[ERISA § 609(a)(2), 609(a)(5)(C)]

Q1-3: What is a medical child support order? 

A medical child support order is a judgment, decree, or order 

(including an approval of a property settlement) that:

m Is made pursuant to state domestic relations law (including a

community property law) or certain other state laws relating to

medical child support (see Q1-8); and

m Provides for child support or health benefit coverage for a child 

of a participant under a group health plan and relates to benefits 

under the plan.

[ERISA § 609(a)(2), Social Security Act § 1908]

Q1-4: Must a medical child support order be issued by a state 

court? 

No. Any judgment, decree, or order that is issued by a court of 

competent jurisdiction or an administrative agency authorized to 

issue child support orders under state law (such as a state child 

support enforcement agency) that provides for medical support of a 

child is a medical child support order.

[ERISA § 609(a)(2)]

5
Q1-5: Who can be an alternate recipient? 

Any child of a participant in a group health plan who is recognized 

under a medical child support order as having a right to enrollment 

under the plan with respect to such participant is an alternate 

recipient.

[ERISA § 609(a)(2)]

Q1-6: What information must a medical child support order 

contain to be a “qualified” order? 

A medical child support order must contain the following 

information in order to be qualified:

m The name and last known mailing address of the participant and 

each alternate recipient. The order may substitute the name and 

mailing address of a state or local official for the mailing address 

of any alternate recipient;

m A reasonable description of the type of health coverage to be

provided to each alternate recipient (or the manner in which such 

coverage is to be determined) ; and

m The period to which the order applies.

[ERISA § 609(a)(3)]

Q1-7: What other requirements must a medical child support 

order meet to be a “qualified” order? 

An 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 

described in Q1-8 below.

[ERISA § 609(a)(4)]

6
 

Q1-8: What state laws relating to medical child support can be 

enforced by a QMCSO? 

At the time that the QMCSO provisions were added to ERISA, 

Congress also added section 1908 to the Social Security Act. Section 

1908 says that states cannot receive Federal Medicaid funds unless 

they have in place specific state laws relating to medical child 

support. States must have laws that require:

m Health insurers to enroll a child under his or her parent’s health 

insurance even if the child was born out of wedlock, does not reside

with the insured parent or in the insurer’s service area, or is not 

claimed as a dependent on the parent’s Federal income tax return;

m Ahealth insurer to enroll a child pursuant to court or administrative 

order without regard to the plan’s open season restrictions;

m Employers and insurers to comply with court or administrative

orders requiring the parent to provide health coverage for a child; and

m Insurers to permit a custodial parent to file claims on behalf of his 

or her child under the noncustodial parent’s health insurance and 

to make benefit payments to the custodial parent or health care

provider.

[ERISA § 609(a)(2), 609(a)(4), Social Security Act § 1908]

Q1-9: What may a QMCSO do to enforce these state medical 

child support laws? 

If a QMCSO refers to these state laws or requires a plan to comply 

with the substantive requirements contained in the state laws, the 

plan must comply with them. For instance, a QMCSO may require a 

plan to enroll a child before the plan’s next open enrollment period.

[ERISA § 609(a)(2), 609(a)(4)]

7
 

Q 

Q 

1-10: Who determines whether a medical child support order is 

qualified? 

The administrator of the group health plan is required to determine 

whether an order is qualified. The 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 administrator must first notify the participant and the alternate 

recipient 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. The administrator must notify those parties of 

its determination whether or not the order is qualified.

[ERISA § 609(a)(5)]

1-11: How long may a plan administrator take to determine 

whether a medical child support order (other than a 

National Medical Support Notice) is qualified? 

Plan administrators must determine whether a medical child 

support order is qualified within a reasonable period of time after 

receiving the order. What is a reasonable period will depend on the 

circumstances. For example, an order that is clear and complete 

when submitted should require less time to review than one that 

is incomplete or unclear. The National Medical Support Notice 

provisions contain separate, specific time limits on the processing 

of the Notice by employers and plan administrators (see Qs 2-3 and 

2-4).

[ERISA § 609(a)(5)]

8
 

 

Q 

Q 

Q 

1-12: If an order names an employee who is not enrolled in the 

plan but is eligible to enroll, can the order be a medical 

child support order within the meaning of the QMCSO 

provisions? 

Yes. An employee who is eligible to enroll is a participant in the 

plan and thus the order is a medical child support order.

[ERISA §§ 3(7), 609(a)(1)]

1-13: In the case of an employee named in a medical child support 

order who is not enrolled, what is the plan’s obligation? 

The plan administrator must determine if the order is qualified and, 

if so, provide coverage to the child. If 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 

must enroll both.

1-14: If an order names an employee who has not yet satisfied the 

plan’s generally applicable waiting period, can the order 

be a medical child support order within the meaning of 

the QMCSO provisions? 

Yes. An employee who has not yet satisfied a plan’s generally 

applicable waiting period (such as requiring that the person be 

employed for a certain number of days or work a certain number of 

hours before being eligible for benefits) is also a participant in the 

plan, and the order is a medical child support order.

[ERISA §§ 3(7), 609(a)(1)]

9
Q 

Q 

Q 

1-15: In the case of an employee named in a medical child 

support order who has not satisfied the plan’s generally 

applicable waiting period, what is the plan’s obligation? 

The plan administrator must determine if the order is qualified. If the 

order is qualified, the administrator should have procedures in place 

so that the child will begin receiving benefits upon the employee’s 

satisfaction of the waiting period. (See Q2-7)

1-16: If a group health plan does not provide any dependent 

coverage, may a medical child support order require 

the plan to provide coverage for a child of a participant 

pursuant to a QMCSO? 

No. As stated in Q1-7, 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. An order may not require a plan 

to provide dependent coverage when that option is not otherwise 

available under the plan.

[ERISA § 609(a)(4)]

1-17: In determining whether a medical child support order is 

qualified, is the plan administrator required to determine 

whether the order is valid under state law? 

No. A plan administrator generally is not required to determine 

whether the issuing court or agency had jurisdiction to issue an 

order, whether state law is correctly applied in an order, whether 

service was properly made on the parties, or whether an individual 

identified in an order as an alternate recipient is in fact a child of the 

participant.

10
Q 

Q 

1-18: Is a plan administrator required to reject a medical child 

support order as not qualified if the order fails to include 

factual identifying information that is easily obtainable by 

the administrator? 

No. In many cases, an order that is submitted to the plan may clearly 

describe the identity and rights of the parties, but may be incomplete 

only with respect to factual identifying information within the 

plan administrator’s knowledge or easily obtained through a 

simple communication with the alternate recipient’s custodial 

parent, the participant, or the state child support enforcement 

agency. 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 a case, the 

plan administrator should supplement the order with the appropriate 

identifying information, rather than rejecting the order as not 

qualified.

1-19: What is a “reasonable description” of type of coverage to 

be provided to the child? 

The order need only provide a coverage description that enables the 

plan administrator to determine which of the available options and 

levels of coverage should be provided to the child. For instance, if 

an order requires that a child be provided any coverage available 

under the plan, the plan administrator would determine the coverage 

available under the plan (e.g., major medical, hospitalization, dental) 

and provide that coverage to the alternate recipient. However, if 

the plan offers more than one type of coverage (e.g., an HMO and 

a fee-for-service option), the order should make clear which should 

be provided or how the choice is to be made. If the order is unclear, 

the plan’s procedures may direct the administrator to contact the 

submitting party, or may provide other selection methods similar to 

those established for the processing of National Medical Support 

Notices (see Q2-4). If the plan does not have such procedures, the 

administrator may have to reject the order.

11
Q1-20: If a plan provides benefits solely through an HMO or other 

managed care organization with a geographically limited 

benefit area, is the plan required to create and provide 

comparable benefits to an alternate recipient who resides 

outside of the HMO’s service area? 

No. As stated in Q1-7, 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 the plan does not ordinarily provide. 

On the other hand, if the child is able to come into the HMO’s 

service area for medical care, the plan would be required to provide 

benefits to the alternate recipient.

[ERISA § 609(a)(4)]

Q1-21: May a plan provide benefits to a child of a participant 

pursuant to a medical child support order that is NOT a 

qualified order? 

Nothing in Title I of ERISA would prohibit the plan from providing 

such coverage pursuant to the terms of any medical child support 

order, regardless of whether the order satisfies the qualification 

requirements of section 609(a), provided that the terms of the 

plan do not otherwise prohibit coverage of the child for any other 

reasons, such as the child does not reside with the participant, or is 

not claimed as a dependent on the participant’s Federal income tax 

return.

12
 

Q 

Q 

1-22: If a child is covered by a group health plan pursuant to 

a QMCSO does the child have any rights to continuation 

coverage? 

Yes. A child covered by a group health plan pursuant to a QMCSO 

is a beneficiary under the plan. The Internal Revenue Service 

(which has jurisdiction over such questions related to continuation 

coverage) has informed the Department that a child covered 

pursuant to a QMCSO is therefore a “qualified beneficiary” with 

the right to elect continuation coverage under COBRA, if the plan 

is subject to COBRA and if the child loses coverage as a result of a 

qualifying event.

[ERISA §§ 609(a)(7)(A) and 607(3)]

1-23: When must a plan begin to provide coverage to an 

alternative recipient pursuant to a QMCSO? 

It is the view of the Department that following a determination that 

an order is qualified, the alternate recipient (and the participant, if 

necessary) must be enrolled as of the earliest possible date following 

such determination. For example, if an insured plan only adds new 

participants or beneficiaries as of the first day of each month, that 

plan would be required to provide coverage to the alternate recipient 

as of the first day of the first month following the determination that 

the order is qualified.

As described in Q’s 1-8 and 1-9, the state laws described in section 

1908 of the Social Security Act require that when a child is enrolled 

in a plan pursuant to a court or administrative order, that enrollment 

be made without regard to open season restrictions.

[Social Security Act § 1908]

13
Q1-24: What information should a group health plan make 

available to parties seeking to obtain health coverage for 

a child before the plan receives a medical child support 

order? 

It is the view of the Department that Congress intended custodial 

parents and/or state child support enforcement agencies acting on 

the child’s behalf to have access to plan and participant benefit 

information sufficient to prepare a QMCSO. Information important 

for that purpose would include the summary plan description, 

relevant plan documents, and a description of any particular 

coverage options, if any, that have been selected by the participant.

The Department believes that Congress did not intend to require 

parties seeking coverage of a child to first submit a medical child 

support order to the plan in order to establish rights to information 

in connection with a child support proceeding. However, a plan 

administrator may condition disclosure of such information on 

receiving information sufficient to reasonably establish that 

the disclosure request is being made in connection with a child 

support proceeding. A disclosure request from a state child support 

enforcement agency should be assumed to be made in connection 

with a child support proceeding.

Q1-25: What effect does an order that a plan administrator has 

determined to be a QMCSO have on the administration 

of the plan? 

The plan administrator must act in accordance with the provisions of 

the QMCSO as if it were part of the plan. In particular, any payment 

for benefits in reimbursement for expenses paid by an alternate 

recipient or an alternate recipient’s custodial parent or legal guardian 

must be made to the alternate recipient, custodial parent, or legal 

guardian.

[ERISA § 609(a)(1), 609(a)(8)]

14
 

Q 

Q 

1-26: If a plan provides that dependents of participants must 

be enrolled in the same coverage and option as the 

participant, must an alternate recipient be enrolled in 

the same coverage and options in which the participant 

is enrolled? 

Yes. Pursuant to section 609, an alternate recipient under a 

QMCSO is treated as a beneficiary under the plan. Accordingly, 

in the view of the Department, an alternate recipient is also 

treated as a dependent of the participant under the plan. 

(However, if a QMCSO specifies that an alternate recipient is to 

receive a particular level of coverage, or option, that is available 

under the plan, but the participant is not enrolled in the particular 

coverage or has not selected the particular option, the plan may 

be required to change the participant’s enrollment to the extent 

necessary to provide the specified coverage to the alternate 

recipient.)

[ERISA § 609(a)(7)(A)]

1-27: If the plan requires additional employee contributions or 

premiums for coverage of a child named in a QMCSO, 

who is obligated to pay that additional amount? 

The medical child support order will ordinarily establish the 

obligations of the parties for the child’s support. In most cases, 

the obligor under a medical child support order will be the 

noncustodial parent who is a participant in a group health plan 

and is responsible for the payment of any costs associated with 

the provision of coverage.

15
Q 

Q 

1-28: What is the plan’s obligation 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 under the terms of the plan, the 

employer should notify the custodial parent, and the child support 

enforcement agency, if the agency is involved. Unless the employer 

is able to withhold the necessary contribution from the participant’s 

paycheck, the plan is not required to extend coverage to the child. 

However, the custodial parent or the agency 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.

1-29: To whom should the plan pay benefits? 

The plan should pay benefits to the alternate recipient, the 

custodial parent, or the provider of health services to the child 

notwithstanding plan terms that may require benefit payments be 

made to the participant. In some instances, payment will be required 

to be made to the state child support enforcement or Medicaid 

agency.

[ERISA §§ 609(a)(8), 609(a)(9), 609(b)(3), Social Security 

Act § 1908(a)(5)]

16
Q1-30: When and under what conditions may a plan disenroll an 

alternate recipient? 

A plan may disenroll an alternate recipient at the same time and 

under the same conditions as it can disenroll other dependents of 

participants under the plan. For instance, if the plan terminates 

coverage when a participant terminates employment, and neither 

the participant nor the alternate recipient elect COBRA continuation 

coverage, the plan may discontinue coverage for the alternate 

recipient. Similarly, if the plan ceases to provide coverage for 

dependents who are over the age of 26, the coverage of an alternate 

recipient who is over the age of 26 may be terminated (assuming 

that continuation coverage is not elected).

17

Section 2 

This section discusses the National Medical Support Notice (Notice), which should 

be used by state child support enforcement agencies to secure coverage for children 

under their noncustodial parents’ group health plans. The following subjects are 

addressed:

q What constitutes a National Medical Support Notice?

q What is the role of a state child support enforcement agency?

q What obligations do an employer and plan administrator have when they receive

a National Medical Support Notice?

q How does an appropriately completed Notice satisfy the QMCSO requirements?

19
 

Q2-1: What is the National Medical Support Notice? 

The National Medical Support Notice (Notice) is a standardized

medical child support order that is to be used by state child support 

enforcement agencies to enforce medical child support obligations. 

The Department of Labor and the Department of Health and Human 

Services regulations implementing the National Medical Support

Notice provisions of the Child Support Performance and Incentive 

Act of 1998 (CSPIA) appear at 29 CFR § 2590.609- 2 and 45 CFR § 

303.32. CSPIA also requires plans sponsored by churches and state 

and local governments to provide benefits in accordance with the

requirements of an appropriately completed Notice, although the

Department of Labor has no interpretive or enforcement authority over

those requirements. For questions with respect to these plans, contact 

your state child support enforcement agency.

[ERISA § 609(a)(5)(C), Social Security Act § 466(a)(19)]

Q2-2: What is the obligation of a state child support enforcement 

agency regarding the Notice? 

Pursuant to the changes made by CSPIA to the child support

enforcement program and the regulations issued by the Department of 

Health and Human Services, the Notice is the exclusive document to 

be used by a child support enforcement agency to enforce the provision

of health care coverage for children of noncustodial parents who are 

required to provide health care coverage through any employmentrelated group health plan pursuant to a child support order and for 

whom the employer is known to the agency.

[Social Security Act § 466(a)(19), 45 CFR § 303.32, CSPIA

§ 401(e) and (f)]

20
Q2-3: What are an employer’s obligations when it receives a 

National Medical Support Notice? 

Ordinarily, an employer may expect to receive a Notice when a child 

support enforcement agency initially enforces an employee’s medical 

support obligation, or when an employee with a previously established

medical support obligation is newly hired. The Notice is comprised of 

Part A, Notice to Withhold for Health Care Coverage (which includes 

an Employer Response) and Part B, Medical Support Notice to Plan 

Administrator (which includes a Plan Administrator Response).

m If the employee named in the Notice is not an employee of the 

employer, if the employer does not maintain or contribute to a

plan that provides dependent coverage, or if the named employee 

is among a class of employees (e.g. part-time or non-union) not 

eligible for enrollment in a plan that provides dependent coverage, 

the employer must check the appropriate box on the Employer

Response and return it to the issuing agency within 20 business days

after the date of the Notice (or sooner if reasonable).

m Otherwise, the employer must transfer Part B of the Notice to the 

group health plan (or plans) for which the child may be eligible 

for enrollment not later than 20 business days after the date of the 

Notice.

For these purposes, the “date of the Notice” means the date that is 

indicated as such on the Notice.

If the employer offers a number of different types of benefits (e.g. 

dental, prescription) through separate plans, and the issuing agency 

has not specified which or all are covered by the Notice, the employer 

should assume all plans are covered by the Notice, and send copies of 

Part B of the Notice to each plan administrator.

21
Q 

The application of a waiting period (such as one requiring that a new 

employee must be employed for a certain amount of time or work a 

certain number of hours) before an employee may enroll in the group 

health plan does not affect the employer’s obligation to transfer Part 

B to the plan administrator(s).

When transferring Part B of the Notice, the employer retains Part A. An

employer that transfers Part B of the Notice to a plan administrator(s) 

may later need to use the Employer Response after it has been notified 

of the qualification of the Notice and has determined that necessary 

employee contributions cannot be withheld from wages.

[Social Security Act § 466(a)(19), 45 CFR § 303.32(c)]

2-4: What are a plan administrator’s obligations upon receipt 

of a National Medical Support Notice? 

A plan administrator who receives a National Medical Support Notice 

must review the Notice and determine whether it is appropriately

completed. The administrator must complete the Plan Administrator 

Response (included with Part B of the Notice), indicating whether the 

Notice is a QMCSO, and return it to the state agency that issued the 

Notice within 40 business days after the date of the Notice.

If the plan administrator determines that the Notice is appropriately 

completed, the administrator is required to treat the Notice as a QMCSO.

The plan administrator in that case must inform the state agency that 

issued the Notice when coverage under the plan of the child named 

in the Notice will begin. The plan administrator also must provide the 

custodial parent of the child (or, in some cases, a named state official) 

with information about the child’s coverage under the plan, such as the

plan’s summary plan description, any forms or documents necessary 

to make claims under the plan, etc.

If the participant is not enrolled and there is more than one option 

available under the plan for coverage of the child, the plan administrator

22
 

 

must also use the Plan Administrator Response to notify the agency 

of that fact, and inform them of the available options for coverage. If 

the agency does not then respond within 20 business days and the plan 

has a “default option,” the plan administrator may enroll the child in 

the default option.

The Department of Labor has issued a regulation, 29 CFR 2590.609-2,

that provides guidance for how administrators of group health plans 

must deal with Notices they receive.

[ERISA § 609(a)(5)(C), 29 CFR § 2590.609-2]

Q2-5: What is an “appropriately completed” National Medical 

Support Notice? 

An “appropriately completed” Notice is a notice that includes the

following information:

m The name of an issuing state child support enforcement agency;

m The name and mailing address of the employee, enrolled or eligible 

for enrollment, who is obligated by a state court or administrative 

order to provide medical support for each named child; and

m The name and mailing address of each child covered by the Notice. 

The name and address of a state or local official may be substituted 

for the address of the child.

A notice may be “appropriately completed” even if some items of

information in the Notice are not included as long as the Notice includes

the information listed above. In addition, if any of the necessary

information described above has been omitted but is reasonably

available to the plan administrator, the Notice should not fail to be 

“appropriately completed” solely because of such omission.

23
 

Q2-6: How does a National Medical Support Notice satisfy the 

QMCSO requirements? 

An “appropriately completed” Notice satisfies the informational

requirements of the QMCSO provisions by:

m Providing the name and last known mailing address (if any) of the 

participant and the name and mailing address of each child covered 

by the order;

m Having the child support enforcement agency identify either the 

specific type of coverage or all available group health coverage;

m Instructing the plan administrator that if a Notice does not designate

either specific type(s) of coverage or all available coverage, it

should assume that all are designated, and further instructing the 

plan administrator that if a group health plan has multiple options 

and the participant is not enrolled, the agency will make a selection 

after the Notice is qualified and, if the agency does not respond 

within 20 business days, the child will be enrolled under the plan’s 

default option if there is one; and

m Specifying that the period of coverage may end for the named child 

only when similarly situated dependents are no longer eligible for 

coverage under the terms of the plan, or upon the occurrence of 

events specified in the Notice.

A Notice also requires the plan to provide to a named child only those 

benefits that the plan provides to any dependent of a participant who is 

enrolled in the plan, and any other benefits that are necessary to meet 

the requirements of the state laws relating to medical child support 

described in Q1-8.

24
 

 

 

Q 

Q 

Q 

2-7: What if the noncustodial parent is not yet eligible to 

enroll because he/she has not satisfied the plan’s generally 

applicable waiting period? 

As noted above in Q1-14, a plan administrator may not find a medical 

child support order, including a Notice, to be not qualified solely

because the participant is subject to a waiting period (such as one

requiring a certain number of months or hours worked). A waiting 

period may, however, affect the procedures necessary for enrollment 

of the named child. 

2-8: What are the duties of an employer that has been notified 

of the qualification of a National Medical Support Notice? 

Following notification of qualification, the employer must determine if

necessary employee contributions may be withheld from the employee’s

wages without violating any applicable withholding limits. Part A of 

the Notice 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 would prevent the employer from withholding the 

employee contributions necessary for coverage, the employer must use

the Employer Response on PartAto notify the issuing IV-D Agency of 

its inability to withhold the necessary amounts. If the amounts necessary

for coverage may be withheld, then the employer must initiate such 

withholding and transmit the withheld amounts to the group health 

plan to pay for the child’s coverage.

2-9: Who pays for coverage provided pursuant to a National 

Medical Support Notice? 

The Notice provides that the employee named in the Notice is liable 

for any employee contributions required under the plan for enrollment 

of the children. However, if Federal or state withholding limitations 

prevent the withholding of the required employee contributions from 

25
the employee’s paycheck, the plan is not required to provide coverage 

to the child. The employer is required to notify the state agency if 

such withholding limitations prevent the withholding of the required 

employee contributions. (See Qs 1-25 and 1-26).

26
 

Section 3 

The following information about ERISA and other laws may be useful sources of 

information about obtaining health care coverage and medical care for children:

Employee Benefits Security Administration - More information about

ERISA, COBRA, the Health Insurance Portability and Accountability Act 

(HIPAA), the Affordable Care Act, and other health benefits laws can be

found at EBSA’s Website. The Website also contains links to other sites with 

information about various health care issues.

Two agencies in the Department of Health and Human Services play significant roles 

in the provision of health care coverage to children:

Office of Child Support Enforcement - The Office of Child Support

Enforcement is responsible for establishing standards and providing guidance

for the Child Support Enforcement Program under Title IV-D of the Social 

Security Act.

Centers for Medicare and Medicaid Services - The Centers for Medicare 

and Medicaid Services administers Medicaid and the State Children’s Health 

Insurance Program (also known as SCHIP), and provides additional guidance

under HIPAA, the Affordable Care Act, and other recently enacted healthrelated laws.

National Child Support Enforcement Association - The National Child Support 

EnforcementAssociation (NCSEA) is a nonprofit membership organization comprised 

primarily of state and local child support enforcement agencies, as well as staff and 

management of state child support enforcement agencies.

Eastern Regional InterState Child Support Association and

Western InterGovernmental Child Support Enforcement Council - The 

Eastern Regional InterState Child Support Association (ERICSA) and the Western 

InterGovernmental 

27
Child Support Enforcement Council (WICSEC) are child support enforcement

professional organizations focusing on issues of interstate child support enforcement.

Each state has a child support enforcement agency. Sometimes this agency is located 

in the state attorney general’s office, but it is frequently found as part of the state’s 

department of social or human services.

28
Appendix 

 

 

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/nationalmedical-support-notice-form

RE:

Employer/Withholder’s Federal EIN Number

Employer/Withholder’s Name

Employee’s Name (Last, First, MI)

Employee’s Social Security Number

Employer / Withholder’s Address

Custodial Parent’s Name (Last, First, MI)

Employee’s Mailing Address

Substituted Official/Agency Name

Custodial Parent’s Mailing Address Substituted Official/Agency Name

Required if Custodial Parent’s mailing address is left blank

Child(ren)’s Mailing Address (if different from

Custodial Parent’s)

Name and Telephone of a Representative of the

Child(ren)

Mailing Address of a Representative of the Child(ren)

Child(ren)’s Name(s) Gender DOB SSN Child(ren)’s Name(s) Gender DOB SSN 

The 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. 

31

 

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:

Child(ren)’s Name(s) (Last, First, Middle DOB

33

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.	 Employer forwarded Part B to Plan Administrator on .

 MM/DD/YY

CONTACT FOR QUESTIONS

Plan Administrator Name: FAX Number: 

Contact Person: Telephone Number: 

Employer Name: Telephone Number: 

Employer Representative Name/Title: Federal EIN: 

(if not provided on Page 1 of this Notice)

Employee Name: Date: 

35

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 document 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.

EMPLOYER 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.

37
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.

38
 

 

 

 

 

 

 

 

 

NATIONAL MEDICAL SUPPORT NOTICE - PART B 

MEDICAL SUPPORT NOTICE TO PLAN ADMINISTRATOR

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 (CSPIA). Receipt of this Notice from the 

Issuing Agency constitutes receipt of a Medical Child Support Order under applicable law. The rights of the parties 

and the duties of the plan administrator under this Notice are in addition to the existing rights and duties established 

under such 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.

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/nationalmedical-support-notice-form

RE:

Employer/Withholder’s Federal EIN Number Employee’s Name (Last, First, MI)

Employer/Withholder’s Name Employee’s Social Security Number

Employer / Withholder’s Address Employee’s Mailing Address

Custodial Parent’s Name (Last, First, MI) Substituted Official/Agency Name

Custodial Parent’s Mailing Address Substituted Official/Agency Name

(Required if Custodial Parent’s mailing address is left blank)

Child(ren)’s Mailing Address (if different from

Custodial Parent’s)

Name and Telephone of a Representative of the

Child(ren)

Child(ren)’s Name(s) Gender DOB 

Mailing Address of a Representative of the Child(ren)

SSN Child(ren)’s Name(s) Gender DOB SSN 

The 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) No persons are required to respond to a collection of 

information unless it displays a valid OMB control number. The time required to complete this information collection is 

estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, 

gather the data needed, and complete the review of the information collection. If you have comments concerning the 

accuracy of the time estimate(s) or suggestions for improving this form please write to: Joseph Piacentini, Office of 

Policy and Research, Department of Labor, Employee Benefits Security Administration, 200 Constitution Avenue NW. 

Room-N5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number. 

OMB control number: 1210-0113. Expiration Date: 10/31/2022.

39

 

 

 

 

 

 

 

 

 

 

 

 

PLAN ADMINISTRATOR RESPONSE

(To be completed and returned to the Issuing Agency within 40 business days after the date of the Notice, 

or sooner if reasonable)

Case # (to be completed by the issuing agency)

This Notice was received by the plan administrator on . 

1.	This Notice was determined to be a “qualified medical child support order,” on . 

Complete Response 2 or 3, and 4, if applicable.

2.	The participant (employee) and alternate recipient(s) (child(ren)) are to be enrolled in the following family 

coverage.

a. The child(ren) is/are currently enrolled in the plan as a dependent of the participant.

b. There is only one type of coverage provided under the plan. The child(ren) is/are included as dependents 

of the participant under the plan.

c. The participant is enrolled in an option that is providing dependent coverage and the child(ren) will be 

enrolled in the same option.

d. The participant is enrolled in an option that permits dependent coverage that has not been elected; 

dependent coverage will be provided.

Coverage is effective as of ( includes waiting period of less than 90 days from date of receipt 

of this Notice). The child(ren) has/have been enrolled in the following option (if plan is insured, identify provider, 

policy and group numbers): . Any necessary withholding should commence if the employer 

determines that it is permitted under State and Federal withholding and/or prioritization limitations.

3.	There is more than one option available under the plan and the participant is not enrolled. The Issuing Agency 

must select from the available options. Each child is to be included as a dependent under one of the available 

options that provide family coverage. If the Issuing Agency does not reply within 20 business days of the date this 

Response is returned, the child(ren), and the participant if necessary, will be enrolled in the plan’s default option, if 

any: . 

4.	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.

5.	This Notice does not constitute a “qualified medical child support order” because: 

The name of the child(ren) or participant is unavailable.

The mailing address of the child(ren) (or a substituted official) or participant is unavailable.

The following child(ren) is/are at or above the age at which dependents are no longer eligible for coverage 

under the plan (insert name(s) of child(ren)).

Plan Administrator or Representative:

Name: Telephone Number: 

Title: Date: 

Address:

41

INSTRUCTIONS TO PLAN ADMINISTRATOR

This Notice has been forwarded from the employer identified above to you as the plan administrator of a 

group health plan maintained by the employer (or a group health plan to which the employer contributes) 

and in which the noncustodial parent/participant identified above is enrolled or is eligible for enrollment.

This Notice serves to inform you that the noncustodial parent/participant is obligated by an order issued 

by the court or agency identified above to provide health care coverage for the child(ren) under the group 

health plan(s) as described on Part B. 

(A)	If the participant and child(ren) and their mailing addresses (or that of a Substituted Official or 

Agency) are identified above, and if coverage for the child(ren) is or will become available, this Notice 

constitutes a “qualified medical child support order”(QMCSO) under ERISA or CSPIA, as applicable. 

(If any mailing address is not present, but it is reasonably accessible, this Notice will not fail to be 

a QMCSO on that basis.) You must, within 40 business days of the date of this Notice, or sooner if 

reasonable:

(1) Complete Part B - Plan Administrator Response - and send it to the Issuing Agency:

(a) if you checked Response 2:

(i) notify the noncustodial parent/participant named above, each named child, and the 

custodial parent that coverage of the child(ren) is or will become available (notification of the 

custodial parent will be deemed notification of the child(ren) if they reside at the same address);

(ii) furnish the custodial parent a description of the coverage available and the effective 

date of the coverage, including, if not already provided, a summary plan description and any 

forms, documents, or information necessary to effectuate such coverage, as well as information 

necessary to submit claims for benefits;

(b) if you checked Response 3:

(i) if you have not already done so, provide to the Issuing Agency copies of applicable 

summary plan descriptions or other documents that describe available coverage including the 

additional participant contribution necessary to obtain coverage for the child(ren) under each 

option and whether there is a limited service area for any option;

(ii) if the plan has a default option, you are to enroll the child(ren) in the default option 

if you have not received an election from the Issuing Agency within 20 business days of the 

date you returned the Response. If the plan does not have a default option, you are to enroll the 

child(ren) in the option selected by the Issuing Agency.

(c) if 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 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 Response 4 on the Plan Administrator Response and return to the 

employer and the Issuing Agency, and notify the participant and the custodial parent; and upon 

satisfaction of the period or requirement, complete enrollment under Response 2 or 3, and

43
(d) upon completion of the enrollment, transfer the applicable information on Part B - 

Plan Administrator Response to the employer for a determination that the necessary 

employee contributions are available. Inform the employer that the enrollment is

pursuant to a National Medical Support Notice.

(B) If within 40 business days of the date of this Notice, or sooner if reasonable, you determine

that this Notice does not constitute a QMCSO, you must complete Response 5 of Part B - Plan

Administrator Response and send it to the Issuing Agency, and inform the noncustodial parent/

participant, custodial parent, and child(ren) of the specific reasons for your determination.

(C) Any required notification of the custodial parent, child(ren) and/or participant may be satisfied

by sending the party a copy of the Plan Administrator Response, if appropriate. You may choose to 

furnish these notifications electronically in accordance with the requirements of the Department of

Labor’s electronic disclosure regulation codified at 29 C.F.R. 2520.104b-1(c).

UNLAWFUL REFUSAL TO ENROLL

Enrollment of a child may not be denied on the ground that: (1) the child was born out of wedlock; (2)

the child is not claimed as a dependent on the participant’s Federal income tax return; (3) the child does 

not reside with the participant or in the plan’s service area; or (4) because the child is receiving benefits 

or is eligible to receive benefits under the State Medicaid plan. If the plan requires that the participant

be enrolled in order for the child(ren) to be enrolled, and the participant is not currently enrolled, you

must enroll both the participant and the child(ren) regardless of whether the participant has applied for

enrollment in the plan. All enrollments are to be made without regard to open season restrictions.

PAYMENT OF CLAIMS

A child covered by a QMCSO, or the child’s custodial parent, legal guardian, or the provider of services to 

the child, or a State agency to the extent assigned the child’s rights, may file claims and the plan shall make 

payment for covered benefits or reimburs ement directly to such party.

44
PERIOD OF COVERAGE

The alternate recipient(s) shall be treated as dependents under the terms of the plan. Coverage of an 

alternate recipient as a dependent will end when similarly situated dependents are no longer eligible for 

coverage under the terms of the plan. However, the continuation coverage provisions of ERISA or other 

applicable law may entitle the alternate recipient to continue coverage under the plan. Once a child is 

enrolled in the plan as directed above, the alternate recipient may not be disenrolled unless:

(1)	 The plan administrator is provided satisfactory written evidence that either:

(a) the court or administrative child support order referred to above is no longer in 

effect, or

(b) the alternate recipient is or will be enrolled in comparable coverage which will 

take effect no later than the effective date of disenrollment from the plan;

(2)	 The employer eliminates family health coverage for all of its employees; or

(3)	 Any available continuation coverage is not elected, or the period of such coverage expires.

CONTACT FOR QUESTIONS

If you have any questions regarding this Notice, you may contact the Issuing Agency at the address and 

telephone number listed above.

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to 

respond to a collection of information unless such collection displays a valid Office of Management and 

Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a 

collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB 

control number, and the public is not required to respond to a collection of information unless it displays 

a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions 

of law, no person shall be subject to penalty for failing to comply with a collection of information if the 

collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately 20 

minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate 

or any other aspect of this collection of information, including suggestions for reducing this burden, to 

the U.S. Department of Labor, Office of Policy and Research, Attention: PRA Clearance Officer, 200 

Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and 

reference the OMB Control Number 1210-0113. Expiration Date: 10/31/2022

45
46
29 CFR 2590.609-2 National Medical Support Notice.

(a) This section promulgates the National Medical Support Notice (the Notice), as mandated by section 401(b) of the Child Support Performance and Incentive Act of 1998 (Pub. L. 

105-200). If the Notice is appropriately completed and satisfies paragraphs (3) and (4) of section

609(a) of the Employee Retirement Income Security Act (ERISA), the Notice is deemed to be a

qualified medical child support order (QMCSO) pursuant to ERISA section 609(a)(5)(C). Section

609(a) of ERISA delineates the rights and obligations of the alternate recipient (child), the participant, and the group health plan under a QMCSO. A copy of the Notice is available on the Internet * at http://www.dol.gov/dol/pwba. 

(b) For purposes of this section, a plan administrator shall find that a Notice is appropriately completed if it contains the name of an Issuing Agency, the name and mailing address (if 

any) of an employee who is a participant under the plan, the name and mailing address of one or 

more alternate recipient(s) (child(ren) of the participant) (or the name and address of a substituted 

official or agency which has been substituted for the mailing address of the alternate recipient(s)), 

and identifies an underlying child support order.

(c) (1) Under section 609(a)(3)(A) of ERISA, in order to be qualified, a medical

child support order must clearly specify the name and the last known mailing address 

(if any) of the participant and the name and mailing address of each alternate recipient 

covered by the order, except that, to the extent provided in the order, the name and mailing 

address of an official of a State or a political subdivision thereof may be substituted for the 

mailing address of any such alternate recipient. Section 609(a)(3)(B) of ERISA requires 

a reasonable description of the type of coverage to be provided to each such alternate 

recipient, or the manner in which such type of coverage is to be determined. Section 609(a)

(3)(C) of ERISA requires that the order specify the period to which such order applies.

(2) The Notice satisfies ERISA section 609(a)(3)(A) by including the

necessary identifying information described in Sec. 2590.609-2(b).

(3) The Notice satisfies ERISA section 609(a)(3)(B) by having the Issuing Agency

identify either the specific type of coverage or all available group health coverage. If an 

employer receives a Notice that does not designate either specific type(s) of coverage or 

all available coverage, the employer and plan administrator should assume that all are 

designated. The Notice further satisfies ERISA section 609(a)(3)(B) by instructing the 

plan administrator that if a group health plan has multiple options and the participant is not 

enrolled, the Issuing Agency will make a selection after the Notice is qualified, and, if the 

Issuing Agency does not respond within 20 days, the child will be enrolled under the plan’s 

default option (if any).

(4) Section 609(a)(3)(C) of ERISA is satisfied because the Notice specifies that the period

of coverage may only end for the alternate recipient(s) when similarly situated dependents are no 

longer eligible for coverage under the terms of the plan, or upon the occurrence of certain specified 

events.

(d) (1) Under ERISA section 609(a)(4), a qualified 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 a law 

relating to medical child support described in section 1908 of the Social Security Act, 42 

U.S.C. 1396g-1.

(2) The Notice satisfies the conditions of ERISA section 609(a)(4) because it

requires the plan to provide to an alternate recipient only those benefits that the plan 

provides to any dependent of a participant who is enrolled in the plan, and any other 

benefits that are necessary to meet the requirements of a State law described in such section 

1908.

(e) For the purposes of this section, an “Issuing Agency” is a State agency that

administers the child support enforcement program under Part D of Title IV of the Social 

Security Act.

*The current Web address is https://www.dol.gov/agencies/ebsa.

47
45 CFR 303.32 National Medical Support Notice.

(a) Mandatory State laws. States must have laws, in accordance with section 466(a)

(19) of the Act, requiring procedures specified under paragraph (c) of this section for the use, 

where appropriate, of the National Medical Support Notice (NMSN), to enforce the provision of 

health care coverage for children of noncustodial parents who are required to provide health care 

coverage through an employment-related group health plan pursuant to a child support order and 

for whom the employer is known to the State agency.

(b) Exception. States are not required to use the NMSN in cases with court or 

administrative orders that stipulate alternative health care coverage to employer-based coverage.

(c) Mandatory procedures. The State must have in effect and use procedures under which:

(1) The State agency must use the NMSN to transfer notice of the provision for 

health care coverage of the child(ren) to employers.

(2) The State agency must transfer the NMSN to the employer within two 

business days after the date of entry of an employee who is an obligor in 

a IV-D case in the State Directory of New Hires.

(3) Employers must transfer the NMSN to the appropriate group health plan 

providing any such health care coverage for which the child(ren) is eligible 

(excluding the severable Notice to Withhold for Health Care Coverage 

directing the employer to withhold any mandatory employee contributions 

to the plan) within twenty business days after the date of the NMSN.

(4) Employers must withhold any obligation of the employee for employee 

contributions necessary for coverage of the child(ren) and send any 

amount withheld directly to the plan.

(5) Employees may contest the withholding based on a mistake of fact. If the 

employee contests such withholding, the employer must initiate withholding 

until such time as the employer receives notice that the contest is resolved.

(6) Employers must notify the State agency promptly whenever the 

noncustodial parent’s employment is terminated in the same manner as 

required for income withholding cases in accordance with Sec. 303.100(e)

(1)(x) of this part.

(7) The State agency must promptly notify the employer when there is no 

longer a current order for medical support in effect for which the IV-D 

agency is responsible.

(8) The State agency, in consultation with the custodial parent, must promptly 

select from available plan options when the plan administrator reports that 

there is more than one option available under the plan.

(d) Effective date. This section is effective October 1, 2001, or, if later, the effective 

date of State laws described in paragraph (a) of this section. Such State laws must be effective 

no later than the close of the first day of the first calendar quarter that begins after the close of 

the first regular session of the State legislature that begins after October 1, 2001. For States 

with 2-year legislative sessions, each year of such session would be regarded as a separate 

regular session.

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U.S. Department of Labor 

Employee Benefits Security Administration

2020