Form 4-19b - Order Determining Objections To Adjusted Order Page 6
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10Form 4-19b Page 6
shall immediately apply to enroll the eligible child(ren) in the “Child
Health Plus” program (the NYS health insurance program for children) and the New York State
Medical Assistance Program or the publicly funded health insurance program in the State where the
custodial parent resides.
And the Court further finds that:
The mother is the Q custodial Qnon-custodial parent, whose pro rata share of the cost or
premiums to obtain or maintain such health insurance coverage is
,
The father is the Q custodial Q non-custodial parent, whose pro rata share of the cost or
premiums to obtain or maintain such health insurance coverage is
;
And the Court further finds that [check applicable box]:
G Each parent shall pay the cost of premiums or family contribution in the same
proportion as each of their incomes are to the combined parental income as cited above;
OR
G Upon consideration of the following factors [specify]:
pro-rating the payment would be unjust or inappropriate for the following reasons [specify]:
and, therefore, the payments shall be allocated as follows [specify]:
; and it is further
OR
G [Where the child(ren) are recipients of managed care coverage under the New York
State Medical Assistance Program] ORDERED that
, the non-custodial parent
herein, shall pay the amount of $
per
toward to the managed care premium under
the New York State Medical Assistance Program;
G [Where the child(ren) are recipients of fee-for-service coverage under the New York
State Medical Assistance Program] ORDERED that
, the non-custodial
parent herein, shall pay up to an annual maximum of $
for the current calendar year to
the New York State Medical Assistance Program upon written notice that the program has paid
health care expenses on behalf of the child(ren) for costs incurred during the current calendar year.
G [Where the child(ren) are recipients of fee-for-service coverage under the New York
State Medical Assistance Program] ORDERED that
, the non-custodial parent
herein, pay as part of the cash medical support obligation up to an annual maximum of $
for the calendar year commencing January 1,
and for every year thereafter to the New
York State Medical Assistance Program upon written notice that the Medicaid program has paid
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