12E-1.031. Noncovered Medical Expenses

(1) Introduction. The Department is responsible for determining and collecting noncovered medical expenses under Section 409.25635, F.S.

(2) Definitions. For purposes of this rule:

(a) “Obligee” means the person to whom support payments are made pursuant to a child support order.

(b) “Obligor” means a person who is responsible for making support payments pursuant to a child support order.

(3) Criteria. The Department will determine and collect noncovered medical expenses when:

(a) The support order requires the obligor to pay all or a percentage of a child’s noncovered medical expenses.

(b) The obligee provides the Department with a written declaration under penalty of perjury that states:

1. Noncovered medical expenses have been incurred on behalf of the dependent child whom the obligor has been ordered to support.

2. The obligee has paid for noncovered medical expenses incurred on behalf of the child.

3. The obligor has not paid all or part of the child’s noncovered medical expenses as ordered.

4. The amount paid by the obligee for noncovered medical expenses and the amount the obligor allegedly owes to the obligee.

(c) The expenses are reasonable and necessary based on the specific language in the support order, the nature of the expense, and whether it is medically necessary as determined by a physician or other healthcare provider.

(d) The obligee has tried at least once to collect the amount owed from the obligor and provides the Department with a copy of the written document used to attempt to collect the amount from the obligor unless the obligee has reason to believe contacting the obligor may result in physical or emotional harm to themselves, to the child, or both.

(e) The obligee has not received services from the Department to determine and collect noncovered medical expenses for the same support order within the last six months.

(f) The last or only child on the case did not emancipate more than 24 months ago.

(g) The medical expenses are equal to or less than 24 months old.

(4) Requests for Service.

(a) If the case meets the criteria in subsection (3) upon request, the Department will send the obligee, by regular mail, the Instructions for Repayment of Medical Expenses Not Covered by Insurance (CS-EF204) (http://www.flrules.org/Gateway/reference.asp?No=Ref-06585), incorporated herein by reference effective 4/5/16.

(b) The obligee must complete a Statement of Medical Expenses Not Covered by Insurance (CS-EF205) (http://www.flrules.org/Gateway/reference.asp?No=Ref-06586), incorporated herein by reference effective 4/5/16, declaring:

1. The amount of noncovered medical expenses the obligee paid for the child.

2. The percentage of the child’s noncovered medical expenses the obligor is required to pay as specified in the support order.

3. The amount the obligor paid for noncovered medical expenses.

4. The amount the obligor still owes the obligee for noncovered medical expenses.

(c) The obligee must complete a Worksheet for Medical Expenses Not Covered by Insurance (CS-EF206) (http://www.flrules.org/Gateway/reference.asp?No=Ref-06587), incorporated herein by reference effective 4/5/16, and provide:

1. Proof of medical expenses for the child.

2. Proof of payment for the medical expenses.

(d) The obligee may only include medical expenses for services received after the date of the support order.

(e) The obligee may only include medical expenses that are equal to or less than 24 months old.

(f) The obligee must complete and return forms Statement of Medical Expenses Not Covered by Insurance (CS-EF205), Worksheet for Medical Expenses Not Covered by Insurance (CS-EF206), and supporting documents to the Department within 30 calendar days from the date on the Instructions for Repayment of Medical Expenses Not Covered by Insurance (CS-EF204).

(g) When the Department is enforcing a support order for another state, the other state has 45 calendar days to return the information.

(5) Determination of Eligible and Ineligible Expenses.

(a) The Department shall review noncovered medical expense requests submitted.

(b) If the obligee returns any, but not all of the required information, or returns incomplete or inaccurate information, the Department will send the obligee, by regular mail, an Information Request for Repayment of Medical Expenses (CS-EF207) (http://www.flrules.org/Gateway/reference.asp?No=Ref-06588), incorporated herein by reference effective 4/5/16, to the parent requesting the missing, incomplete, or corrected information.

(c) The obligee must complete and return the requested information to the Department within 21 calendar days from the mail date on the Information Request for Repayment of Medical Expenses (CS-EF207).

(d) If the obligee does not return the Statement of Medical Expenses Not Covered by Insurance (CS-EF205), Worksheet for Medical Expenses Not Covered by Insurance (CS-EF206), and supporting documents within 30 calendar days the request is considered abandoned and the Department closes the request for services.

1. The Department will send the obligee, by regular mail, a Status Update Medical Expenses Not Covered by Insurance (CS-EF208) (http://www.flrules.org/Gateway/reference.asp?No=Ref-12347), incorporated herein by reference effective 11/20, to inform the obligee the information did not arrive timely.

2. If the obligee returns the requested information after 30 calendar days, but before six months, the Department will re-open the request for services.

3. If the other state returns the requested information after 45 calendar days, but before six months, the Department will re-open the request for services.

(e) The Department shall review the forms and supporting documents returned by the obligee to determine which expenses and payments qualify for repayment, and the amount of noncovered medical expenses owed to the obligee.

1. The Department accepts proof of payment as paid by the obligee unless the document shows someone other than the obligee made the payment.

2. The payment date of the expense must be within 24 months of the date the obligee signed the form CS-EF205.

3. The Department will determine the amount owed to the obligee by the obligor only for expenses the obligee has already paid.

4. If the obligee has partially paid an expense, the Department considers only the amount paid for repayment.

(f) The Department will not attempt to obligate and collect if:

1. The expense does not show who received the service or the patient name is missing.

2. The submitted expense is for a child not included in the support order.

3. The submitted expense has the child’s name in freehand text rather than printed and does not appear to be a part of the original document.

4. The child emancipated before the medical services were incurred.

5. The submitted expense was not an uninsured medical, dental, or prescription medication expense ordered to be paid on behalf of a child as provided in Section 61.13(1)(b), F.S., or a similar law of another state.

6. The obligee does not provide proof of payment of the expense.

7. Someone other than the obligee paid the expense and there is no proof the obligee reimbursed the individual for the expense.

8. The expense was paid more than 24 months before the obligee signed the Statement of Medical Expenses Not Covered by Insurance (CS-EF205).

9. The expense was previously established as a noncovered medical expense owed by the obligor.

10. The expense is the same as another expense within the documentation provided by the obligee.

11. The expense is a health insurance, dental insurance, or prescription medication insurance premium payment.

12. The expenses are not reasonable and necessary based on the specific language in the support order, the nature of the expense, and whether it is medically necessary as determined by a physician or other healthcare provider.

13. The obligee did not initially try to collect the expense payment directly from the obligor.

14. The expense is interest charged on a credit or loan account while waiting for the obligor to reimburse noncovered medical expenses.

(g) If some or all of the expenses are not eligible for repayment, the Department will send the obligee, by regular mail, the Medical Expenses Not Eligible for Reimbursement (CS-EF209) (http://www.flrules.org/Gateway/reference.asp?No=Ref-06590), incorporated herein by reference effective 4/5/16. The form will list the receipt number, date the expense was incurred, type of service, name of service provider, name of child, and reason the Department cannot ask for repayment.

1. The obligee will have 15 calendar days from the mail date to provide the Department more information documenting why the expenses are eligible.

2. The other state will have 30 calendar days from the mail date to provide the Department more information documenting why the expenses are eligible.

(6) Notice of Proceeding. When the Department determines expenses claimed by the obligee as noncovered medical expenses are subject to reimbursement by the obligor, the Department will send the obligor, by regular mail, the Notice of Proceeding to Establish the Amount Owed for Medical Expenses Not Covered by Insurance (CS-EF210) (http://www.flrules.org/Gateway/reference.asp?No=Ref-12348), incorporated herein by reference effective 11/20, by regular mail.

(7) Uncontested.

(a) If the obligor does not contest the Notice of Proceeding to Establish the Amount Owed for Medical Expenses Not Covered by Insurance (CS-EF210) within 25 days of the Notice, the obligor is deemed to have waived the right to contest.

(b) Upon expiration of the contest period, the Department shall file a certified copy of the uncontested notice and the Notice to the Clerk of the Circuit Court Depository Determination of Noncovered Medical Expenses (CS-EF211) (http://www.flrules.org/Gateway/reference.asp?No=Ref-06592), incorporated herein by reference effective 4/5/16, with the depository.

(8) Contested. Upon entry of a final order by the Department following an administrative hearing, the Department shall file a certified copy of the final order establishing the amount of noncovered medical expenses, if any, and the Notice to the Clerk of the Circuit Court Depository Determination of Noncovered Medical Expenses (CS-EF211) with the depository.

Rulemaking Authority 61.13(1)(b)7., 409.25635(9), 409.2557(3)(j) FS. Law Implemented 61.17, 409.25635 FS. History–New 4-5-16, Amended 11-12-20.