Form 4-6 - Temporary Order Of Support (And Referral To Support Magistrate) (Page 4 of 9) in pdf

Form 4-6 Page 4

G No legally-responsible relative has health insurance coverage available for the child(ren), but the

child(ren) may be eligible for health insurance benefits under the New York “Child Health Plus”

program or New York State Medical Assistance Program, or the publicly funded health insurance

program in the State where the custodial parent resides,

G No legally-responsible relative has health insurance coverage available for the child(ren), but the

child(ren) are currently enrolled in the New York State Medical Assistance Program,

IT IS THEREFORE ORDERED that [specify name(s) of legally-responsible relative(s)]:

G continue to maintain health insurance coverage for the following eligible dependent(s) [specify]:

under the above-named existing plan for as long as it remains available;

G enroll the following eligible dependent(s) [specify]:

under the following health insurance plan [specify]:

immediately

and without regard to seasonal enrollment restrictions and maintain such coverage as long as it remains

available in accordance with

[IV-D cases]: G the Medical Execution, which shall be issued immediately by

the Support Collection Unit, pursuant to CPLR 5241

G the Medical Execution issued by this Court

[Non-IV-D cases]: G the Qualified Medical Child Support Order.

The cost or premiums, if any, to be paid by the legally-responsible relative(s) to obtain or maintain

such benefits be allocated as follows between the parties [specify]:

Such coverage shall include all plans covering the health, medical, dental, optical and prescription drug

needs of the dependents named above and any other health care services or benefits for which the

legally-responsible relative is eligible for the benefit of such dependents; provided, however, that the

group health plan is not required to provide any type or form of benefit or option not otherwise

provided under the group health plan except to the extent necessary to meet the requirements of Section

1396(g-1) of Title 42 of the United States Code. The legally-responsible relative(s) shall assign all

insurance reimbursement payments for health care expenses incurred for (his)(her) eligible

dependent(s) to the provider of such services or the party having actually incurred and satisfied such

expenses, as appropriate;

G IT IS THEREFORE ORDERED that the custodial parent [specify name]:

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

Form 4-6 - Temporary Order Of Support (And Referral To Support Magistrate) Page 4