COURT OF COMMON PLEAS

DIVISION OF DOMESTIC RELATIONS

HAMILTON COUNTY, OHIO

Date :

Plaintiff	Case No:

-vs-

File No: E-

CSEA No:

Defendant	Judge

Cash Medical Support Order

(__) The Obligor’s annual income is less than or equal to 150% of the federal poverty level, therefore the Court makes no cash medical support order at this time. A Shared Liability Order shall issue if no insurance available.

(__) The Obligor’s annual income exceeds 150% of the federal poverty level, and neither party currently has private health insurance coverage available at a reasonable price for the child(ren). Therefore, the Court sets a cash medical order against the Obligor in the amount of $ per month plus a 2% processing charge. This order is effective and is in addition to any existing child support order.

Both parties shall notify the CSEA if private health insurance coverage for the children subject to this order becomes available. The CSEA shall determine whether the private health insurance provides accessible primary care services and is available at a reasonable cost. The cost is presumed reasonable if the annual cost of obtaining the coverage is five percent or less of the annual income of the party to whom it is available. If the CSEA determines that the private insurance is reasonably priced and accessible, the CSEA shall notify both parties that the person to whom the coverage is now available is ordered to secure and maintain health insurance for the child(ren) without an additional order or hearing.

If private health insurance coverage for the child(ren) is obtained at a later date, the cash medical support previously established shall terminate on the last day of the month preceding the month in which private health insurance goes into effect. A Shared Liability Order shall issue.

(__) The Obligor’s annual income exceeds 150% of the federal poverty level, and one or both of the parties currently have available private health insurance coverage for the child(ren). Therefore, the Obligor is not ordered to pay cash medical support at this time. However, if private health insurance coverage for the children becomes unavailable or terminates, the Obligor shall be ordered to pay $ per month plus a 2% processing charge as cash medical support. This payment is in addition to any other existing child support order and shall become effective on the first day of the first month following the unavailability or termination of the private health insurance coverage on the child(ren).

If the private health insurance coverage lapses, the child support order shall be modified to $ per month plus a 2% processing charge. (See attached worksheet) This modification shall take effect on the first day of the first month following the termination of the health insurance coverage and without further notice to any party.

Both parties are ordered to notify the CSEA immediately if the private health insurance coverage for the child(ren), subject to this order, becomes unavailable or lapses for any reason. A Qualified Medical Child Support Order shall issue.

______________________________

Judge/Magistrate