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Medical Expense Reimbursement Enforcement

Procedures for Enforcement of Health Care Expenses

1) Who Is Eligible?

If you, as the Requesting Party, have incurred out of pocket expenses for your minor child/children’s medical care and your court order states one or both parties are responsible for a percentage of uninsured health care expenses, you are entitled to assistance in collecting a percentage of the uninsured amount. If your original or most recent court order was entered after October 1, 2004, and it includes an “annual ordinary medical” expense, you are not eligible for enforcement, until your out of pocket expenses meet or exceed the “annual ordinary medical” expense amount established in your order.

The Friend of the Court (FOC) will only enforce health care expenses that are less than one year old from the date the expense was incurred, or within six months after the date of the insurance company’s final payment or denial of coverage.

Some court orders contain a provision entitled ORDINARY MEDICAL EXPENSE (OME). The OME will be listed in your order, it may be $357 per child per year.  The court orders have a specific monthly amount to be paid for OME.  Ordinary Medical expenses include co-payments and deductibles, and most uninsured medical-related costs for children, but do not normally include remedial care costs such as first-aid supplies, cough syrup, vitamins and other routine over the counter items.

The OME affects the medical expense reimbursement because the OME must be exceeded before any reimbursement amount is calculated.  If the OME is not exceeded, no reimbursement of medical may be reimbursed. If proof of the OME is not provided to the FOC, the OME will be deducted from the submitted health care expenses to determine what expenses are to be reimbursed.  For example: 

2013 medical expenses
$1000.00
Minus 2013 OME $ 357.00
Extraordinary Medical Expenses
$ 643.00
The Responding party’s percentage (50%)
x      .50
Amount the Responding party must pay
$ 321.50

 

If medical treatment lasts more than one year, then the OME must be deducted for every year that treatment is being done.  Orthodontics for example, may last 22 months.  If the treatment starts 4/1/2013 and the orthodontic contract is for 22 months (until February of 2015) the OME must be deducted for 2013 and 2014.   For example:

2013 medical expenses
$5000.00
22 month contract 4/1/13
Minus 2013 OME
$  357.00
Minus 2014 OME 
$  357.00
Extraordinary medical expenses
$4286.00
Responding party’s percentage (50%) x       .50
Amount responding party must pay
$2143.00


The Eaton County Friend of the Court has a form you should use to keep track of the Annual Ordinary Health Care expenses you must incur before submitting claims for reimbursement from the other Party. The annual Ordinary Health Care expense that you must incure before submittng claims for reimbusrement from the other Party commences January 1st if each year and runs to December 31st of that year.

In the event that your prior order does not specify an Ordinary Health Care amount, the prior responsibility percentages shall be utilized.

Extraordinary Medical Expenses (EME): The health care expenses of all payers of child support will be processed as “extraordinary medical expenses” and the expenses will be apportioned between the parties according to the medical expense percentages established in the support order. The OME noted in the support order is not deducted from the medical expense claim of the payer of child support.

To submit a formal claim, the following process must be followed:

1.  Using the FOC official Ordinary Medical Log, and Demand for Medical Forms the requesting party must request payment as soon as possible after the expenses have occurred, or within six months after the date of the insurance company’s final payment or denial of coverage.  Each expense must be entered on the form itemized.  In addition, you must provide copies of the bills, receipts and proof of insurance payment.  The bills must include the following:

                        1) The name of the child receiving the services

                    2) The name of the provider
                    3) The date of service
                    4) The nature of the service
                    5) Explanation of benefits (EOB) from the insurance providers
                    6) Copy of signed orthodontic contract if applicable
                    7) Statement from the provider.

YOU MUST allow the other party 28 days to respond to your request for payment.  If no response or payment is received within 28 days, you may send the White copy of the Demand for  Medical Reimbursement and a copy of the Ordinary Medical Log, with the copies of all the bills, and also the above noted information.  The forms must be completed in their entirety or they will not be processed. 

Any medical expenses submitted to the FOC for processing with the completed forms, but which do not have the required proof attached, will be returned unprocessed.  DO NOT FAX THE MEDICAL PACKET.

Upon receipt of the official forms and appropriate documentation by the FOC, the Complaint will be processed and a determination will be issued to the parties setting forth the amount owed.  If a written Objection is not filed within 21 days after the date the Notice was mailed, the FOC will set up a separate medical reimbursement account. 

OBJECTION HEARING:  If a written Objection is filed within 21 days from the date of the Notice, a hearing will be scheduled before the Referee.  You must bring all health care bills, receipt of payment, verification of any insurance payments, and any other pertinent proofs.  The Referee will issue an order setting the amount of payment that must be made.  Any frivolous objections may result in an order for costs. 

The FOC will not directly pay funds to the provider of health care services.  Any monies collected by FOC for medical reimbursement will be sent to the payee.  It is the payee’s responsibility to pay the provider.

SUBSEQUENT PAYMENT:  You must notify the FOC in writing if the other party pays you directly after the complaint is mailed. 

Medical enforcement questions can be answered by calling: Tammy Dreps, Medical Enforcement Caseworker, (5l7) 543-6850, ext. 1349, or by emailing her at tdreps@eatoncounty.org. To obtain the Annual Ordinary Heath Care Expense Form and Demand for Medical Expense Reimbursement Form, you may download the forms from the links below.

Medical Expense Reimbursement Forms

1) If you would like to download and print the INSTRUCTIONS for the Eaton County Friend of the Court Annual Log Form and the Demand for Payment of Uninsured Health Care Expenses Form, click here: [Instructions regarding Annual Log Form and Demand for Payment of Uninsured Health Care Expenses Form]

2. If you would like to download and print the Eaton County Friend of the Court Annual Log for Uninsured Health Care Expenses Form, click here: [Eaton County Friend of the Court Annual Log for Uninsured Health Care Expenses Form]

3) If you would like to download and print the Eaton County Friend of the Court Demand for Payment of Uninsured Health Care Expenses Form, click here: [Demand for Payment of Uninsured Health Care Expenses Form]

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