Form 4-7 - Order Of Support (Page 5 of 9) in pdf

Form 4-7

Page 5

[specify name]:

under the following health insurance plan [specify, if known]:

which provides the following health insurance benefits [specify extent and type of benefits, if

known, including any medical, dental, optical, prescription drug and health care services or other

health care benefits]:

G Health insurance coverage is available to both of the parents as follows:

Name

Health Insurance Plan

Premium or Contribution

Benefits

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.

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;

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;

Form 4-7 - Order Of Support Page 5

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