The forms identified in this rule are referenced within various
rules contained within division 5101:12 of the Administrative Code. The
effective or revised effective dates of the forms are as follows:
(A)JFS 03377,
"Employer/Health Plan Administrator Health Insurance Verification
Request" (rev. 1/2015);
(B)JFS 03399,
"Notice of Administrative Mistake of Fact Hearing" (rev. 1/201510/2019);
(C)JFS 04031,
"Notice Regarding Cash Medical Support Order":(rev. 10/2019);
(1)On or after February 11, 2019 and prior
to March 28, 2019, use version dated February 2019 (rev 2/2019);
(2)On or after March 28, 2019, use version
dated March 2019 (rev. 3/2019);
(D)JFS 04032,
"Notice to Provide Cash Medical Support":(rev. 10/2019);
(1)On or after February 11, 2019 and prior
to March 28, 2019, use version dated February 2019 (rev 2/2019);
(2)On or after March 28, 2019, use version
dated March 2019 (rev. 3/2019);
(E)JFS 04033,
"Notice to Provide Private Health Insurance":(rev. 10/2019);
(1)On or after February 11, 2019 and prior
to March 28, 2019, use version dated February 2019 (rev 2/2019);
(2)On or after March 28, 2019, use version
dated March 2019 (rev. 3/2019);
(F)JFS 04034,
"Notice of Selection of Health Plan Option" (rev. 1/2015);
(G)JFS 04035,
"Notice of Available Health Plan Options" (rev. 1/2015);
(H)JFS 04036,
"Notice of Medical Support Enforcement Activity" (rev. 2/201910/2019);
(I)JFS 04037,
"Medical Support Enforcement Administrative Mistake of Fact Hearing
Decision" (rev. 2/201910/2019);
(J)JFS 04098,
"Notice Regarding NMSNNational Medical Support Notice Withholding
Requirements" (rev. 1/2015);
(K)JFS 07053,
"Notice of Medical Support Mistake of Fact Hearing": (rev. 3/2019);
(1)On or after February 11, 2019 and prior
to March 28, 2019, use version dated February 2019 (rev 2/2019);
(2)On or after March 28, 2019, use version
dated March 2019 (rev. 3/2019);
(L)JFS 07058,
"Medical Support Mistake of Fact Hearing Determination" (rev.
2/2019); and
(M)OMB 0970-0222,
"National Medical Support Notice" (NMSN) (expiration
date 8/31/2019www.acf.hhs.gov/css).
Effective: 1/15/2020
Five Year Review (FYR) Dates: 10/18/2019 and 01/15/2025
Certification: CERTIFIED ELECTRONICALLY
Date: 12/30/2019
Promulgated Under: 119.03
Statutory Authority: 3125.25
Rule Amplifies: 3125.03
Prior Effective Dates: 01/01/2015, 01/15/2017, 02/14/2019