Medical Support Obligations
About Medical Support
When a support order is issued through the Domestic Relations Section (DRS), it may require a party to provide health insurance for their dependents and/or to pay part of any medical expenses not covered by insurance. This is called "Medical Support." Under the current guidelines, the first $250 per person per year is built into the basic child support obligation. After the $250 threshold has been met, reimbursement can be sought pursuant to the terms of your Court Order.
Documentation of medical support expenses for which a party is seeking reimbursement must be provided to the other party no later than March 31st of the year following the calendar year in which the final bill was received by the party seeking reimbursement. All qualifying medical support expenses must be received by the insurance company and sent to the other party within one (1) year of the date the expense is incurred. Failure to comply may make the expense ineligible for reimbursement.
Before DRS will perform any services regarding medical support, all persons seeking reimbursement will need to sign and date the Authorization for the Release of Information and place same on file with the DRS
Medical Support Inclusions
Medical support includes reasonable expenses for necessary medical services and supplies including, but not limited to, surgical, prescription, dental, orthodontic and optical services. Over-the-counter items such as vitamins, cough syrup, bandages, etc. are not eligible for reimbursement.
Medical support may also include, if specifically stated in the Court's order, cosmetic, chiropractic and psychiatric/psychological services.
Most recent support orders contain provisions for medical support. If your order does not include medical support, it may be modified to include medical support.
Parties must communicate and cooperate to fulfill their medical support obligations.
Proof of Medical Coverage
Within 15 days after the entry of a support order which requires a party to provide medical insurance for a dependent, the party ordered to provide insurance must provide written proof that he / she has obtained, or at least applied for the appropriate medical insurance. The party directed to provide insurance must send the following items to the other party within 15 days:
- The name of the health insurance company
- Address for mailing claims to the insurance company.
- A copy of the benefit booklet or coverage contact.
- A description of all deductible and co-payments.
- A description of any restrictions on using the insurance (such as prior approval for hospital admissions, and how such approval should be obtained).
- Insurance cards
- Insurance claim forms (at least 5 copies)
- Insurance policy identification numbers
The party directed to provide insurance must also provide the Domestic Relations Office with a copy of insurance cards for each dependent covered by the Court Order within 15 days. Copies of the cards may be faxed to 570-825-9841.
To get his / her claim paid, the Plaintiff must follow the insurance company's rules (example: he/she may have to follow claim pre-approval procedures, see only participating physicians, etc.).
If a claim is denied because the Plaintiff did not follow the insurance company's rules, the Defendant cannot be made to pay any expenses that would have been covered.
Submission of Claims
Immediately after receiving medical support services, the Plaintiff should have all bills submitted to any and all insurance companies providing coverage for the patient. If applicable, the insurance company should be instructed to send its check to the Plaintiff. The Plaintiff should also keep a copy of the bill. The Plaintiff must follow the insurer's claim procedures and send along one of the following:
- A copy of court order requiring medical insurance coverage for the child and/or Plaintiff
- A release signed by the insured (Defendant) permitting the insurance company to communicate directly with the Plaintiff
If an insurance company refuses to provide information or pay claim directly to a Plaintiff, the Plaintiff may request that the Domestic Relations Office issue a "Qualified Medical Support Order" to the insurance company so that they may add the Plaintiff to their record as an alternate payee.
Acceptance of Claims & Payment of Uncovered Expenses
Acceptance of Claims: After receiving a claim, the insurance company will send a claim acceptance letter to the insured showing how much, if anything, it will pay on the bill. The insured should keep it for his/her records. If there is an amount not paid by the insurance company, that amount should be recorded on the medical enforcement form. A separate form must be used for each individual covered by the Court Order.
Once the unreimbursed amount for an individual has reached $250, a copy of the medical enforcement form(s) should be sent to the Defendant with copies of the medical bills, receipts for payment, insurance statement and a letter indicating the amount that is to be paid and where to send the payment. Do not send any information to the Domestic Relations Office at this time. The terms of your support order outline what percentage of medical support expenses each party must pay.
Also, keep in mind that in new cases, the bills may not have been for services rendered prior to the effective date of the initial order on the case. Also, the annual deductible of $250 will be prorated on a monthly basis for the year that your initial order became effective.
An example would be if your order became effective 6/1/10, only bills for medical services incurred after June 1, 2010 are eligible for reimbursement and the deductible for each dependent during 2010 would be $145.81 ($250 divided by 12 months equals $20.83 per month times 7 months plus $145.81).
- Pay by check or money order: When sending a medical reimbursement payment to the Plaintiff, the Defendant should send the Plaintiff a check or money order for the amount the Defendant owes the Plaintiff in 30 days. If the Defendant pays the Plaintiff cash, he/she should have the Plaintiff sign a receipt for the payment.
- Use Certified Mail: The Plaintiff should send the information to the Defendant by certified mail. The Plaintiff should keep the green certified mail receipt as proof that the Defendant received the letter.
If the parties cannot reach an amicable resolution regarding reimbursement amounts and a schedule for repayment, a request for reimbursement of medical support expenses must be submitted to the DRS and the reimbursement amount and schedult will be set by the DRS. The request for reimbursemnt must include:
- A completed medical enforcement form for each Dependent (a separate form must be completed for each calendary year)
- A copy of the medical bill and receipt for payment for each submission listed on the form.
- A signed "Authorization for the Release of Information" form.
- A copy of the insurance denial form for any claim, if applicable.
- A copy of the contract for payment of orthodontic services (i.e.braces), if applicable.
- A listing of any partial payments the Defendant has made to you, if applicable.
- Proof that you served the Defendant with notice of expenses(i.e. certified letter receipt).
- If any of the required documentation is not included in the packet, the packet cannot be processed and will be returned to you in its entirety.
Please withhold any requests for status updates for at least 30 days from submission due to the volume of work involved in processing reimbursement requests.
If all required doocumentation has been provided, the request will be reviewed and the Defendant will be notified by the DRS of the amount he/she owes towards the obligation. If there is no valid dispute of any of the expenses, the Defendant's share of the medical support expenses will be added to your PACSES account and collected on the schedule approved or directed by the DRS. If there is a legitimate dispute regarding the valadity or eligibility of submitted expenses, a court hearing will be scheduled and both parties will be directed to appear to provide testimony so that the Court may make a determination to resolve the dispute.