Qualified Medical Child Support Order (QMCSO)
The Employee Retirement Income Security Act (ERISA) requires employer-sponsored 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. 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.
The QMCSO provisions apply to "group health plans" subject to the Employee Retirement Income Security Act of 1974 (ERISA), as amended. For this purpose a "group health plan" generally is a plan that is sponsored by an employer or employee organization (or both) and provides "medical care" to employees, former employees or their families.
"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.
ERISA does not apply to plans maintained by Federal, state or local governments; churches; or 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.
In order for the plan administrator to determine which of the available options and levels of coverage should be provided to the child, the order should provide a clear coverage description. For instance, if an order requires that a child be provided any coverage available under the plan, the plan administrator would determine what coverage is 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. Lacking such procedures, the administrator may have to reject the order.
A plan administrator must respond to state authority within 40 days of receiving order, and the employer must forward to administrator or respond directly to state authority within 20 days. A copy of the determination should also be provided to the employee/participant. Failure to comply may result in legal action brought by alternate recipient or state authority.
FAQs
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.
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.
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. 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.
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.
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