1 National Medical Support Notice Part A

NATIONAL MEDICAL SUPPORT NOTICE PART-A
NOTICE TO WITHHOLD FOR HEALTH CARE COVERAGE
This Notice is issued under section 466(a)(19) of the Social Security Act, section 609(a)(5)(C) of the Employee
Retirement Income Security Act of 1974 (ERISA), and for State and local government and church plans, sections 401(e)
and (f) of the Child Support Performance and Incentive Act of 1998. Receipt of this Notice from the Issuing Agency
constitutes receipt of a Medical Child Support Order under applicable law. The information on the Custodial Parent and
Child(ren) contained on this page is confidential and should not be shared or disclosed with the employee. NOTE:
For purposes of this form, the Custodial Parent may also be the employee when the State opts to have policies to enforce
against custodial parents.
National Medical Support Order/Notice (NMSN)

Termination Order/Notice – if checked, see page 2

Notice Date:

Court or Administrative Authority:

Issuing Agency:

Order Date:

Address:

Order Identifier:
Document Tracking Identifier:

Case Identifier:

Employer website:

Telephone Number:

See NMSN Instructions:
https://www.acf.hhs.gov/sites/default/files/documents/
ocse/omb_0970-0222_a_instructions.pdf

Email Address:
FAX Number:

RE:
Employer/Withholder’s Federal EIN Number

Employee’s Name (Last, First, MI)

Employer/Withholder’s Name

Employee’s Social Security Number

Employer/Withholder’s Address

Employee’s Mailing Address

Custodial Parent’s Name (Last, First, MI)

Substituted Official/Agency Name

Custodial Parent’s Mailing Address

Substituted Official/Agency Address
(Required if Custodial Parent’s mailing address is left blank)

Child(ren)’s Mailing Address (if different from
Custodial Parent’s)
Name and Telephone of a Representative of the
Child(ren)
Child(ren)’s Name(s)

Sex

DOB

SSN

Mailing Address of a Representative of the Child(ren)

Child(ren)’s Name(s)

Sex

DOB

SSN

The order requires the child(ren) to be enrolled in
all health coverages available; or only the following coverage(s):
Medical
Dental
Vision
Prescription drug
Mental health
Other (specify):
THE PAPERWORK REDUCTION ACT OF 1995 (P.L. 104-13) Public reporting burden for this collection of
information is estimated to average 10 minutes per response, including the time reviewing instructions, gathering and
maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and
a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number. OMB control number: 0970-0222. OMB Expiration Date: 11/30/2025.
NMSN – Part A

Page 1 of 6

LIMITATIONS ON WITHHOLDING
The total amount withheld for both cash and medical support cannot exceed
% of the employee’s
aggregate disposable weekly earnings. The employer may not withhold more under this National Medical Support
Notice than the lesser of:
1. The amounts allowed by the Federal Consumer Credit Protection Act (15 U.S.C., section 1673(b));
2. The amounts allowed by the State of the employee’s principal place of employment; or
3. The amounts allowed for health insurance premiums by the child support order, as indicated
here:
.

PRIORITY OF WITHHOLDING
In addition to the limitations on withholding that determine the maximum amount of earnings the employer may withhold
for paying support, each state has policy or law that prioritizes the kinds of support to be paid. If the employee does not
earn enough to pay all ordered support, then the employer should consult the state’s priority of withholding to
determine the order of importance between all orders for current support, medical support, support arrears, and
interest on the support arrears. The employer must consider all support orders received for each employee.
For more information about specific state and territory limitations and priority of withholding, see the OCSE Medical
Support Matrix at https://www.acf.hhs.gov/css/contact-information/state-medical-support-contacts-andrequirements.

Additional Information for Termination Order/Notice
Unless the employee has indicated that they want to continue coverage voluntarily, you are
required to terminate health care coverage for the child(ren) identified in this NMSN order/
notice if the Termination Order/Notice checkbox is checked on page 1.
1. Effective date of medical support order/notice termination: ________________________
2. Reason for termination of order/notice: ________________________________________
3. Child(ren) for whom the order/notice is terminated:
Last, First, Middle Name of Child(ren):

NMSN – Part A

DOB:

_________________________________________________

____________________________

_________________________________________________

____________________________

_________________________________________________

____________________________

_________________________________________________

____________________________

_________________________________________________

____________________________

_________________________________________________

____________________________

_________________________________________________

____________________________

_________________________________________________

____________________________

Page 2 of 6

Section 1 – No Enrollment Possible

EMPLOYER RESPONSE

The employer knows that the plan administrator cannot enroll dependents in employer-provided health
care coverage for the employee named on page 1 because: (select all that apply)
1. The employee named in this Notice has never been employed by this employer.
2. We, the employer, do not offer our employees the option of purchasing dependent or family health care
coverage as a benefit of their employment.
3. The employee is among a class of employees (for example, part-time or non-union) that are not eligible
for family health care coverage under any group health care plan maintained by the employer or to
which the employer contributes. If the employee is only temporarily ineligible for health care
coverage, do not check this box, and advance to Section 2.
4. Health care coverage is not available because employee is not employed by employer:
Effective date of separation:
Reason for separation:
Last known telephone number:
Last known address:
Address line 1:
Address line 2:
Address line 3:
City:

State:

ZIP Code:

ZIP Code Ext:

(If new employment information is known, add at #6).
5. State or Federal withholding limitations and/or prioritization prevent the withholding from the
employee’s income of the amount required to obtain coverage under the terms of the plan. (See page
2 for description and instructions.)
6. Other (new job information for employee, child adequately covered by third party, other reason for no
coverage):
New employer (if known):

New employer telephone number:

New Employer Address:
Address line 1:
Address line 2:
Address line 3:
City:

State:

ZIP Code:

ZIP Code Ext:

Section 2 – Dependent Enrollment Not Yet Available
7. The participant is subject to a waiting period that expires ____________________ (more than 90 days from
the date of receipt of this Notice), or has not completed a waiting period, which is determined by some
measure other than the passage of time, such as the completion of a certain number of hours worked
(describe here: _______________________________________________). At the completion of the waiting
period, the Plan Administrator will process the enrollment.
8. Employee is on an unpaid leave of absence. Expected date of return: ___________________
Section 3 – Dependent Coverage Available
9. Employer forwarded Part B - Medical Support Notice to Plan Administrator on this date: _______________
NMSN – Part A

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COMPLETED BY:
Employer Company Name:
Employer Representative Details:
First Name:
Middle Name or MI:
Title:
Email:
Telephone Number:
FEIN:

Plan Administrator Name:
Contact Person Details:
First Name:
Middle Name or MI:
Title:
Email:
Telephone Number:
FEIN:

NMSN – Part A

Last Name:
Suffix Name:

Fax Number:

Last Name:
Suffix Name:

Fax Number:

Page 4 of 6

NOTICE AND GENERAL INSTRUCTIONS TO EMPLOYER
This document serves as legal notice that the employee identified on this National Medical Support Notice is
obligated by a court or administrative child support order to provide health care coverage for the child(ren)
identified on this Notice. This National Medical Support Notice replaces any Medical Support Notice that the
Issuing Agency has previously served on you with respect to the employee and the children listed on this Notice.
The document consists of
1. Part A - Notice to Withhold for Health Care Coverage for the employer to withhold any employee
contributions required by the group health care plan(s) in which the child(ren) is/are enrolled; and
2. Part B - Medical Support Notice to Plan Administrator, which must be forwarded to the Administrator of
each group health care plan identified by the employer to enroll the eligible child(ren) or completed by the
employer if the employer serves as the health care Plan Administrator.
An employer receiving this legal Notice is required to complete and return Part A – Employer Response. If
group health care coverage is not available to the employee named herein, or the employee was never or is no
longer employed, the employer is required to complete Part A – Employer Response and return it to the Issuing
Agency with the appropriate response checked.
If you, the employer, provide the health care benefits to the employee, forward Part B – Medical Support
Notice to Plan Administrator – Plan Administrator Response to the health care Plan Administrator of your
organization. If the employee’s health care benefits are administered through another organization, including a
labor union, forward Part B – Medical Support Notice to Plan Administrator to the labor union or other organization
acting as the Plan Administrator for completion. If the employee has already enrolled the child(ren) in health
care coverage, the employer must forward Part B – Medical Support Notice to Plan Administrator to the
Plan Administrator for completion and submittal to the Issuing Agency.
Keep a copy of Part A - Notice to Withhold for Health Care Coverage to notify the Issuing Agency if the
employee separates from service for any reason, including retirement or termination. You may also use Part A to
notify the Issuing Agency of any changes or lapses in health care coverage.
For step-by-step supplemental instructions, see https://www.acf.hhs.gov/sites/default/files/documents/ocse/
omb_0970-0222_a_instructions.pdf.
EMPLOYER RESPONSIBILITIES
1.

If dependent health care coverage is available for which the child(ren) identified above may be eligible, you
are required to:
a.

Transfer not later than 20 business days after the date of this Notice a copy of Part B - Medical
Support Notice to Plan Administrator to the Administrator of each appropriate group health care
plan for which the child(ren) may be eligible, complete Section 3, item 9, and

b.

Upon notification from the Plan Administrator(s) whether the child(ren) is/are enrolled or cannot be
enrolled, either
1) Withhold from the employee’s income any employee contributions required under each group
health care plan, in accordance with the applicable law of the employee’s principal place of
employment and transfer employee contributions to the appropriate plan(s), or
2) Complete Section 1, item 5, of the Employer Response to notify the Issuing Agency that
enrollment cannot be completed because of prioritization or limitations on withholding.

c.

NMSN – Part A

If the Plan Administrator notifies you that the employee is subject to a waiting period that expires
more than 90 days from the date of its receipt of Part B - Medical Support Notice to Plan
Administrator, or whose duration is determined by a measure other than the passage of time (for
example, the completion of a certain number of hours worked), complete Section 2, item 7, of the
Employer Response to notify the Issuing Agency of the enrollment timeframe and notify the Plan
Administrator when the employee is eligible to enroll in the plan and that this Notice requires the
enrollment of the child(ren) named in the Notice in the plan.
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2.

If the Termination Order/Notice checkbox is checked, you are required to terminate the NMSN/Qualified
Medical Child Support Order (QMCSO) and health care coverage for the child(ren) identified in the order
unless the employee has indicated that they want to continue coverage voluntarily. If this employee
is also under a wage withholding order for payment of child support, release of this health care insurance
order may result in an increase in the amount of earnings available to remit to the state disbursement unit
as child support. Release of this health care insurance order does not negate your obligation to comply
with wage withholding and/or other health care insurance orders for this employee.

DURATION OF WITHHOLDING
The child(ren) shall be treated as dependents under the terms of the plan. Coverage of a child as a dependent will
end when conditions for eligibility for coverage under terms of the plan no longer apply. However, the continuation
coverage provisions of ERISA may entitle the child to continuation coverage under the plan. The employer must
continue to withhold employee contributions and may not disenroll (or eliminate coverage for) the
child(ren) unless:
1. The employer is provided satisfactory written evidence that:
a. The court or administrative child support order referred to in this Notice is no longer in effect; or
b. The child(ren) is or will be enrolled in comparable coverage that will take effect no later than the
effective date of disenrollment from the plan; or
2. The employer eliminates family health care coverage for all its employees; or
3. Any available continuation coverage is not elected, or the period of such coverage expires.
POSSIBLE SANCTIONS
An employer may be subject to sanctions or penalties imposed under State law and/or ERISA for discharging an
employee from employment, refusing to employ, or taking disciplinary action against any employee because of
medical child support withholding, or for failing to withhold income or transmit such withheld amounts to the
applicable plan(s) as the Notice directs. Sanctions or penalties may be imposed under State law against an
employer for failure to respond and/or for non-compliance with this Notice.
NOTICE OF TERMINATION OF EMPLOYMENT
In any case in which the above employee’s employment terminates, the employer must promptly notify
the Issuing Agency listed above of such termination. This requirement may be satisfied by sending to the
Issuing Agency a copy of Part A - Notice to Withhold for Health Care Coverage, with Section 1, item 4,
checked or any notice the employer is required to provide under the continuation coverage provisions of ERISA or
the Health Insurance Portability and Accountability Act.
EMPLOYEE LIABILITY FOR CONTRIBUTION TO PLAN
The employee is liable for any employee contributions that are required under the plan(s) for enrollment of the
child(ren) and is subject to appropriate enforcement. The employee may contest the withholding under this Notice
based on a mistake of fact (such as the identity of the obligor). Should an employee contest the withholding under
this Notice, the employer must proceed to comply with the employer responsibilities in this Notice until notified by
the Issuing Agency to discontinue withholding. To contest the withholding under this Notice, the employee
should contact the Issuing Agency at the address, telephone number, or email listed on page 1 of this
Notice. With respect to plans subject to ERISA, it is the view of the Department of Labor that Federal Courts have
jurisdiction if the employee challenges a determination that the Notice constitutes a Qualified Medical Child
Support Order.
CONTACT FOR QUESTIONS
If you have any questions regarding this Notice, you may contact the Issuing Agency at the address, telephone
number, or email listed on page 1 of this Notice.
For Frequently Asked Questions (FAQs) about the NMSN, see Resource Library | The Administration for
Children and Families (hhs.gov).

NMSN – Part A

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