A Review of Medical Child Support: Background, Policy, and Issues

CRS Report for Congress
A Review o f M edical Child Support:
Background, Policy, and Issues
November3,2003
Ca rmen So lomon-Fears
Specialist in Social Legislation
Domestic Social Policy Division

Congressional Research Service ˜ The Library of Congress

A Review of M edical Child Support:
Background, Policy, and Issues
Summary
Medical child support i s t he legal p rovision of paym ent o f m edical, d ental,
prescri p t i on, a n d o t h er heal t h care ex p enses o f d ependent chi l d ren. It can i n cl ude
provisions to cover health insurance costs as well as cash p ayments for unreimbursed
medical ex penses. According t o 2001 Ch ild Support Enforcement (CSE) data, 93%
of medical child support i s p rovided i n t he form of health insurance coverage. T he
requirement for m edical child s upport i s apart of al l child support orders
(adm i n i s t e r ed b y C S E agenci es), and i t only p ertains t o t he parent’s dependent
children. Activities undertaken by CSE agencies t o establish and enforce m edical
child support are eligible for federal reimbursement at the C SE matching rate of 66%.
The m edical child support p r o c e s s requires t hat a state C SE agency notify the
employer of a noncustodial p a r e n t w h o o wes child support, that the p arent i s
obligated to provide health care coverage for h is or her d ependent children. CSE
agencies notify employers of a m edical ch ild support o rder via a s tandardiz ed federal
form called t he National M edical Support No tice. The p lan administrator must then
determine whether family health care coverage is available for which t he dependent
children m ay be eligible. If eligible, t he plan administrat or is required t o enroll t he
dependent child in an appropriate plan, and notify t he noncustodial parent’s employer
of the p remium amount to be withheld from t he employee’s p aycheck.
Although establishment o f a medical support o rder is a p rerequisite to enforcing
the order, i nclusion of a health insurance order does not necessarily mean that health
insurance coverage is actually provided. According t o C SE program d ata, in 2001,
only 49% of child support o rders i ncluded health insurance coverage, and the h ealth
insurance o rder was complied with in only 18% of the cases. M o s t policym akers
agree t hat h eal t h care coverage for d ependent chi l d ren m ust b e avai l abl e, accessi bl e,
affordable, and stable. S ince 1977 and s poradically through 1998, Congr e s s h as
passed l egislation t o hel p states effectivel y establish and enforce m edical ch ild
support. The National M edical S upport Notice, mandated by 1998 law and
promulgated i n M arch 2001, was v iewed as a means t o s ignificantly i m p r ove
enforcement o f m edical child support — to date only about half the s tates are using
the Notice. The 1998 law also called for an advisory body to design a m edical child
support i ncentive which would b ecome part of the C SE performance-based i ncentive
paym ent s ys tem — a recommendation was made to Congress in 2001 to indefinitely
delay d evelopment o f a medical child support i ncentive m ainly b ecause it was argued
that the appropriate data was not yet available upon which t o b ase s uch an i ncentive.
Im provi ng t h e est abl i s hm ent and enforcem ent o f m edi cal chi l d support h as been
hampered to some ex tent by fact ors s uch as high health care costs, a decline i n
employer-provided h ealth insurance coverage, an i ncrease i n t he share o f h eal t h
in s u r a n ce costs borne by employees, and the l arge number o f uninsured children.
This report p rovides a legislative history of medical support provisions in the C SE
program, describes current policy with respect to medical chi l d s upport, ex amines
availabl e d ata, and d iscusses s ome o f t he issues related t o m edical child support.
This report will not be updated.

Contents
Background ......................................................1
Current Policy ....................................................2
Medical Child Support Data .........................................6
Census Data ..................................................6
CSEProgram Data .............................................9
SIPP Data ...................................................12
DataSummary ...............................................13
Establishment of Health Insurance Order as Part of Child
Support Award/Order ..................................14
EnforcementofHealth InsuranceOrder .......................14
Issues ..........................................................15
Slow Progress in Establishing and Enforcing Medical Support .........15
ExaminingtheHealthCareCoverageofBothParents ................17
Accessibility of Health Care Coverage ............................18
In centives for S eeking M edical Support ...........................19
What Is Meantby“ReasonableCost”? ............................21
Cooperation Among Child Support, Medicaid, and S CHIP Agencies ....22
Alternate M ethods to Offset Health In surance o r M edicaid C osts ...22
Closing t he Gap Between Those Eligible for M edicaid and Those
Enrolled ............................................23
Legi slative T imetables for M edical Support Have Not Been Met ........24
Appendix A: Legislative History of Medical Child Support P rovisions ......27
P . L. 95-142, Medicare-Medicaid Anti-fraud and Abuse Amendments
(H.R. 3 ), Enacted October 25, 1977 .........................27
P.L. 98-369, the Deficit Reduction Act of 1984 (H.R. 4170), Enacted
J uly 18, 1984 ...........................................27
P.L. 98-378, the C hild Support Enforcement Amendments of 1984
(H.R. 4325), Enacted Augu st 16, 1984 .......................27
ImplementingRegulations ..................................28
MoreRegulations .........................................28
P.L. 103-66, the Omnibus Budget Reconciliation Act of 1993
(H.R. 2264), enacted Augu st 10, 1993 .......................29
P.L. 104-193, the P ersonal R esponsibility and W ork Opportunity
Reconciliation Act o f 1996 (H.R. 3734), enacted Augu st 22, 1996 30
P.L. 105-200, the C hild Support P erformance and Incentive Act of 1998
(H.R. 3130), enacted J u ly 16, 1998 ..........................30
Appendix B: Health Care Coverage of Custodial Children — 1993 .........32

ListofFigures
Fi gu re 1. Health In surance and Child Support Awards ....................7
ListofTables
Table 1 . C hild Support Award Status an d Inclusion of Health In surance i n
Child Support Award, b y S elected Char acteristics o f C ustodial Mothers,
1999 ........................................................8
Table 2 . M edical Child Support, FY2001 ..............................10
Table B.1. Provision for Health Care Costs i n t he Child Support
Award or Agreement, 1993 .....................................32
Table B.2. Health Care Coverage of Children i n C ustodial Families i n 1993 . . 3 2

A R eview o f Medical C hild Support:
Background, Policy, and Issues
Background
Most Am eri cans v i ew h eal t h care for t h ei r chi l d ren and for t hem s el ves as one
of their t op concerns. The adverse consequences of go ing without health insurance
m ay i ncl ude unm et heal t h and d ent al n eeds, l o wer recei p t of prevent i v e s ervi ces,
avoidable hospitaliz ations, i ncreased likelihood of receiving ex pensive emergency
room care, and reduced likelihood that th e doctor i s familiar with the p atient’s
medical history. From a public health pers pective, early and frequent monitoring of
children’s h ealth is a k ey component to ensuring the appropriate growth and h ealthy
development of children. From a family perspective, health insuran c e c o v erage
greatly reduces parental financial and emotional s tress . M edical child support
benefits families b y i ncreas ing t he incid e n c e o f noncustodial parents who obtain
private h ealth insurance coverage for t heir dependent children. W ith medical child
support, Congress found a w a y t o m ake noncustodial parents responsible for t heir
children and lessen t ax payer burden by s hifting costs from t he tax payers back to the
noncustodial parents.
Since 1977, Congress has t ried to offset some of the costs associated with the
Medi cai d p rogram by al l o wi ng st at es t o requi re Medi cai d reci pi ent s t o assi gn t h ei r
child support rights t o t he state and allowing the s tate to pursue reimbursement of the
cost of Medicaid b enefits provided t o t he child from t he child’s noncustodial parent
(in 1984 mandatory assign ment became l aw). S i nce 1984, Congress has t ried t o
increase p rovision of private h ealth care coverage for children whose noncustodial
paren t h a s access to emp loyer-related o r group health insurance t hat i s p rovided at
a reasonable cost. This is seen as a way to make noncustodial parents responsible for
their children and lessen t ax payer burden by s hifting costs from t he tax payers back
to the noncustodial parents. Fo r a detailed l egislative h istory, s ee Appendix A.
In 1984, federal l aw require d t hat s tate Child Support Enforcement (CSE)
agencies petition f o r t h e i nclusion of medical support as p art o f any child support
order wheneve r h ealth care coverage is available t o t he noncustodial parent at
reasonable cost. A 1993 amendment t o t he Employee Retirement Income S ecurity
Act (ERIS A) required employer-sponsored group health plans t o ex t end h ealth care
coverage to the children of a parent/employee who is divorced, s eparat ed, or never
m a r r i e d when ordered t o d o s o b y t he st at e C S E agency vi a a Q ual i fi ed M edi cal
Child Support Order (QMCSO). The 1996 welfare reform l aw further s trengt hened
medical support b y s tipulating t hat all orders enforced by the s tate CSE agency m ust

include a p rovision for h ealth care coverage.¹ The 1996 law also d irected the C SE
agency to notify t he noncustodial parent’s employer of the employee’s m edical child
support obligation. To help obtain h e a l t h c a r e coverage for children, a 1998 law
authorized the creation of t he National M edical Su p port Notice (NMSN), a
st andardi z ed form , t h a t i s t he ex cl usi v e document which must be used by all s tate
CSE agencies. An appropriately completed NMSN i s considered to be a “Qualified
Medical Child Support Order,” an d a s s uch m ust b e honored by the noncustodial
parent’s employer’s group health plan.
The reader should recogn iz e t hat efforts t o i m p r ove the establishment and
e n f o rcement o f m edical child support n eed to be viewed in the current contex t o f
high health care costs, a decl i n e i n employer-provided h ealth insurance coverage
(which is the foundation o f t he current medi cal child support s ys tem), an i ncrease i n
the s hare of health insurance costs borne by empl o ye e s , and a l arge number o f
childre n w h o a r e uninsured. M oreover, cash s upport and medical support are not
al ways compatible. For ex am ple, if premium s , c o-paym ents, and deductibles of
noncustodial parents rise, fairness might suggest that the cash child support p ayment
of noncustodial parents b e reduced to refl ect paym ent o f additi o n a l m edical costs.
The result, however, would b e t h a t custodial parents would h ave l ess i ncome t o
provide for t he basic food, clothing, and shelter n eeds o f t heir dependent children;
conversely, if medical support i s not ava ilable, the family will undoubtedly face dire
economic ci rcumstances if a child becomes seriously ill.
The publ i c a n d pol i cym akers general l y agree t hat est abl i s hm ent and
enforcement o f m edical support, where i t i s available o n reasonable t erms, p romotes
family re s ponsibility, improves children’s access t o h ealth care, and u sually saves
federal and state dollars. This report p rovi des a legi slative h istory of medical support
provisions in the C SE program, describes current policy with respect to medical child
support, ex amines data on medical child suppor t , a n d d iscusses s ome o f t he issues
related t o m edical child support.
CurrentPolicy
Federal l aw mandates t hat s tates h ave p rocedures under which all child support
orders are required t o i nclud e a p rovisi on for t he health care coverage of the child
(section 466(a)(19) of the S ocial S ecurity Act). M edical suppor t i s t h e legal
provi si on of paym ent o f m edi cal , d ent al , prescri p t i on, and o t h er heal t h care ex p enses
for d ependent children b y t he noncustodial parent. It can include provisions to cover
heal t h i n surance cost s as wel l as cash p aym ent s for unrei m bursed m edi cal ex penses.
The requirement for m edical child support i s a part of the child support o rder, and it
only p ertains t o t he parent’s dependent ch ildren. The reader should note t hat s tates
can establish child support o rders (and t hereby medical child support o rders) either

¹ CSE a ge n c y s t a ff carry out this duty by determi ning the employment s tatus of t he
noncustodial parent and whether heal t h i n surance c overage i s a va ilable f or his or her
dependents. If such coverage is available, the CSE agency notifies t h e e mp l o yer of the
employee’s medical child support obligation and the employer’s responsibility to thereby
enroll the dependents of t he employee in the health care plan.

by a j udicial or administrative p rocess (i.e., t hrough t he state courts or through t he
state C SE agencies). Activities undertaken by the s tate CSE agencies t o establish and
enforce m edical support are eligible f o r f e d eral reimbursement at the general CSE
matching rate of 66%.²
Medical support can take several forms. The noncustodial parent may b e
ordered t o: (1) p rovide health insurance if available t hrough h is or her employer, (2)
pay for privat e health insurance ( h ealth care coverage) premiums or reimburse the
custodial parent for all or a portion o f t he
costs o f h ealth insurance obtained b y t he
Nat i onal Ce ns us Dat acustodial parent for t he child, o r (3) pay
1999 — 56% of child support ordersadditional amounts t o c over s ome or all of
included hea l t h i nsurance coverage;ongoing medical bills as reimbursement for
parents complied with 49% of theseuninsured medical costs.³
health insurance orders
CSE P rogram DataC ongress has real i z ed for m any ye a r s
2001 — 49% of child support ordersth at medical support enforcement activities
included health insurance covera ge;need to be strengthened. C ongress
parents complied with 49% of theserecognized early in the implementation of
health insurance ordersth e C SE program t hat m any noncustodial
parents h ad private h ealth insurance
coverage available t hrough employers,
unions or other groups and t hat s uch coverage could b e ex t ended when available at
reasonable cost t o p rovide for d ependent s’ medical ex penses. The medic a l c h i l d
support p rovisions benefit families b y i ncreasing t he incidence o f noncustodial
parents who obtain h ealth insuran c e c overage for t heir dependent children.
Moreover, the m edical child support p ro v i s i o n s r e sult in cost savings t o s tates and
t h e federal governm ent s b y reduci n g M edi cai d ex p endi t u res w hen s uch h eal t h care
insurance i s available t o families who are eligible for M edicai d s ervices .⁴
According t o federal regu lations (45 C FR 303.31), for both families who have
assign ed their m edical support rights t o t he state and families who have applied for
CSE s ervices, t he CSE agency m ust:
(1) P etition t he court or administrative authority to include in the child support
order h ealth insurance t hat i s available t o t he noncustodial parent at reasonable
cost in new o r m odified child support o rders, unless t he child has s atisfac t o ry
health insurance other than Medicai d;

² For backgr ound information on t he CSE progr am, s ee: Congression a l R e s e a r ch Service
(CRS) Report 97-408, Child Support Enforcement: New Reforms and Potential Issues, by
Ca rmen Solomon-Fears.
³ U.S. Department of Health and Human Services, Administration f or Ch ildren and
Families, Office of Child Support Enforcement, Essentials for Attorneys in Child Support
En f o r c e m ent, 3rd Edition, 2002 at [http:// www.acf.hhs.gov/progr ams/cse/pubs/200 2 / r e p o r t s /
essentials/index.html ].
⁴ U.S. Department of Health and Human Services, Admin istration f or Children and
Families, Office of Child Support Enforcement, OCSE-AT -88-15, Actio n T ransmittal,
Medical Support Enforcement , Sept. 26, 1988.

(2) P etition t he court o r administra tive authority t o include medical support
whether o r not — (a) health insurance at reasonable cost i s actually available t o
the noncustodial parent at the time the o rder is entered; or (b) m odification o f
current coverage to incl ude the child(ren) in question i s immediat el y possible;
(3) Establish written criteria t o i dentify cas es not included under t he previous
two provisions where there is a high potential for obtaining medical support
based o n — (a) evi d ence t h at heal t h i n sura n c e m a y b e avai l abl e t o t he
noncustodial parent at a reasonable cost, and (b) facts, as defined b y s tate law,
regu lation, procedure, o r other d irec tive, which are sufficient t o warrant
modification o f t he ex isting s upport o rder to include health insurance coverage
for a dependent child(ren);
(4) P etition t he court or administrative authority to modify child support o rders
for cases t h at are l i k el y t o h ave access t o h eal t h i n surance t o i ncl ude m edi cal
support i n t he form of health insurance coverage;
(5) P rovide the custodial parent with information pert a i ning t o t he health
insurance policy which has b een secu red for the d ependent child(ren);
(6) Inform t he Medicaid agency when a new or m odified court or administrative
order for child support i ncludes m edi c a l s u p port and provide specific
informationtotheMedicaidagencywhen t he information i s available;
(7) If h ealth insurance i s available t o t he noncustodial parent at reasonable cost
and has not been obtai ned at t he time the order is entered, take steps t o enforce
the h ealth insurance cove r a ge r e q u i red b y t he support o rder and p rovide the
Medicai d agency with the necessary information;
(8) P eri odi cal l y com m uni cat e w i t h t h e M edi cai d age n c y t o d et erm i n e i f t here
have been l apses i n heal t h i n sura n c e c overage for M edi cai d appl i cant s and
recipients;and
(9) R equest employers and other groups offering health insurance coverage that
is be i n g enforced by the C SE agency to notify t he CSE agency o f l apses i n
coverage.
In addition, a m edical child support o rder must contain t h e f o l l o wing
information i n order to be “qualified”: (1) t he name and l ast known m ailing address
of t h e p ar t i c i p a n t a n d each chi l d covered b y t he order, ex cept t hat t he order m ay
substitute the nam e a n d mailing address of a stat e or l ocal offici al for t he mailing
address o f any child covered b y t he order; (2) a reasonable d escription o f t he type of
health coverage to be provided (or the manner i n which such coverage is to be
determined); and (3) the period t o which the order applies.
To help obtai n h ealth care coverage for children, a 1998 law authoriz ed the
creation of t he NMSN. The NMSN is a s tandardiz ed federal form t hat all state C S E
agencies are s upposed to use when i ssuing a medical support o rder to employers. An
appropriately completed NMSN i s considered to be a “Qualified Medical Child
Support Order,” and as s uch m ust b e honored by the noncustodial parent’s
employer’s group health plan.⁵

⁵ Generally, a state court or agency may require an ERISA-covered health plan to provide
health benefits coverage to children by i ssuing a Qualified M edical Child Support Order ;
the medical support order is “qualified” i f i t i ncludes t he information mentioned above. T he
(continued...)

Cash child support collections by CSE agencies are distributed in several ways,
including in the form o f m edical support. They may b e s ent t o t he f a mily, divided
between the state and federal governments, used as incentive payments t o states, or
used for m edical support (and s ent t o t he Medicaid agency o r t he family). Fo r
FY2001, total child support collections were distributed as follows: 87.7% went to
families; 5.3% went to the s tates; 4.7% went to the federal government; 1.8% were
paid out as incentive p ayments t o s tates; and 0.5% was p aid as m edical support. To
the ex t en t t h a t m e d ical support h as been assign ed to the s tate, m edical support
col l ect i ons are forwarded t o t h e M e d i cai d agency for distribution. Otherwise, the
amount collected as medical support i s forwarded to the family.⁶ (It s hould b e noted
that the p rovision of medical support i n t he form of health insurance coverage is not
quantified i n t he above data.)
In general, health insurance i s p referred over o t h e r types o f m edical support
because i t u s u a l l y i s r e l a t i v e l y i n e x p e n s i v e f o r t h e e m p l o ye e / noncustodial parent (due
to the employer contribution), i t i s eas ier for the C SE agency to monitor, and i t can
cover children who otherwise would b e d ep endent on Medicaid b enefits (at t ax payer
ex pense).⁷ In FY2001, medical s upport orders were issued in the form of health
insurance i n 9 3% of the cases that included a medical support o rder (see Table 2).
Th e c o n f e rence report o n t he Child Support Enforcement Amendments of 1984
(which became P .L. 98-378) stated:
“... the conferees believe that t h e best l ong run s olution t o achievi ng medical
insurance coverage f or all f amilies i s t he use of private medical insurance which
is or can be made available t hrough a parent’s employer.”⁸
The m edical child support p rocess requi res t h a t a state C SE agency issue a
notice t o t h e e m p l oyer of a noncustodial parent, who is subject to a child support
order i ssued by a court o r administrative agency, inf o r m ing t he employer of the
parent’s obligation t o p rovide health care coverage for t he child(ren). T he employer
must then determine whether family health care coverage is available for which t he
dependent child(ren) may b e eligible, and if so, t he em p l oyer must notify t he plan

⁵ (...continued)
National M edical Support Notice i s a federally-r equired f orm t hat s erves t he same purpose
as the QMCSO. T he standardized form was design e d i n c o nsultation with a f ederal
workgr oup that included r epresentatives of maj or employers, payroll associations, i nsurance
admi nistrators and government r epresentatives. T heir intent was t o provi de employers with
a standardized set of f orms , processes and timeframes — something employers had
requested.
⁶ In F Y 2001, medical support payments t o f amilies amounted to $94.3 million, up from
$32.3 million i n FY1994 (and $7.5 million i n F Y 1993, the first year in which data were
collected).
⁷ U.S. Depart ment of Health and Human Services, Administration f or Children and
Families, Office of Child Support Enforcement, Essentials for Attorneys in Child Support
Enforcement, 3rd Edition, 1992, p. 109.
⁸ U.S. Congress, Conference Committees, Child Support Enforcement Amendments of 1984,
conf e r ence report t o accompany H.R. 4325, 98^th Cong., 2^nd sess., H.Rept. 98-925
(Washington, GPO, 1984), p. 52-53.

administrator of each plan covered b y t he National M edical S upport Notice. If the
dependent child(ren) is eligible for coverage under a plan, t he plan administrator is
required t o enroll t he dependent child(ren) i n a n appropriate plan. The plan
administra t or also must notify t he noncustodial parent’s employer of the p remium
amount to be withheld from t he employee’s p aycheck.⁹
Medical Child Support D ata
This section ex amines data from t hree different sources: n ational d ata from t he
U.S. Census Bu reau, s tate CSE p rogram data from t he f e d e r a l Office of Child
Support Enforcement (OCSE), and l ongitudi nal d ata from t he Survey of In come and
Program P articipation. All o f t he data indicate t hat m uch m ore n eeds t o b e done to
improve the establishment and enforcem ent o f m edical support, in accordance with
current law. In reviewing t he data, i t i s important to n ote that (1) i n s ome cas es
children d id not receive a child support award of any k ind, cash o r m edical care; (2)
even i f t h ere w as a cash award, i n m any cases, h eal t h i n surance coverage w as not
i n cl uded i n t he award; a n d (3) even when h ealth insurance coverage was i ncluded,
in many cases, i t was not actually provided b y t he noncustodial parent.
CensusData
The U.S. C ensus Bureau periodically coll ects n ational s urvey i nformation o n
c h i l d s u pport. The C ensus Bureau interviews a random sample of single-parent
families t o gather d ata t hat can be used to assess the p erformance of noncustodial
parents i n p aying child support and providi ng health insurance coverage. The Census
data are b ased on all s ingl e-parent families i n t he United S tates with children under
age 2 1 w h o are living apart from t heir other p aren t. The C en sus d at a are more
comprehensive t han C SE program d ata but do not disaggregate t he data on a s tate-by-
statebasis.
Fi gure 1 displays data obtained from April supplements to the C ensus Bureau’s
Current P opulation S urvey. These s upplem ents provide information o n t he receipt
of child support p ayments b y p arents living with their o wn children whos e o ther
parent is not living with the family. Fi gure 1 only d isplays i nformation from cases
in which t he mother i s t h e c ustodial parent.¹⁰ Fi gure 1 indicates that during t he
period from 1989-1999, the p ercentage of ch ild support awards t hat i ncluded h ealth
insurance i ncreased from 40.1% to 55.6%. Thus, i n 1999 about 56% of mothers
awarded child support p ayments h ad health insurance i ncluded i n t heir award. This
coincides with congressional efforts t o make h eal t h care coverage part o f t h e chi l d
support obligation. However, the ex amina tion o f enforcement, i.e., whether health
insurance was actually provided, s h o w s a different picture. During the 1989-1999
period, the p ercentage of child support awards t hat i ncluded h e a l t h i n s u rance i n
which h ealth insurance coverage was act ually provided b y t he father dropped almost

⁹ U.S. Departme nt of Labor, Pension an d Welfare Benefits Admi nistration, Federal
Register, v. 65, no. 249, National M edical Support Notice, Dec. 27, 2000, p. 82137.
¹⁰ T he 1991 Survey was t he first s urvey t o i nclude information on custodial fathers.

28%, from 67.6% in 1989 to 48.9% in 1999. Thus, i n 1999, only 49% of custodial
m o t h ers ex p ect i n g t o recei ve heal t h benefi t s for t hei r chi l d ren act ual l y di d s o.
Figure 1 . Health Insurance a nd Child Support Aw a rds
⁸⁰
⁷⁰^he^al^t^hⁱⁿ^s^u^r^aⁿ^c^eⁱⁿ^c^l^u^de^dⁱⁿ
⁶⁰^chⁱ^l^d^su^p^p^o^r^t^a^w^a^r^d^a^s^pe^r^c^en^t^a^g^e^of^al^l^c^hi^l^d^s^u^pp^o^r^t
⁵⁰^aw^a^r^ds^he^al^t^hⁱⁿ^s^u^r^aⁿ^c^e^a^c^t^u^a^l^l^y
⁴⁰^e^r^c^ent^p^r^ovⁱ^d^e^d^by^f^a^t^h^er^a^s^a^pe^r^c^en^t^a^g^e^of^aw^a^r^ds^wⁱ^t^h
^P^he^al^t^hⁱⁿ^s^u^r^aⁿ^c^e
³⁰^he^al^t^hⁱⁿ^s^u^r^aⁿ^c^e^a^c^t^u^a^l^l^y
²⁰^p^r^ovⁱ^d^e^d^by^f^a^t^h^er^a^s^a^pe^r^c^en^t^a^g^e^of^al^l^c^hi^l^d^s^u^pp^o^r^t
^aw^a^r^ds
¹⁰
⁰
¹⁹⁸⁵¹⁹⁸⁷¹⁹⁸⁹¹⁹⁹¹¹⁹⁹³¹⁹⁹⁵¹⁹⁹⁷¹⁹⁹⁹
^Ye^a^r^s
^Source:^P^r^epared^by^th^e^C^on^g^r^es^sⁱ^on^al^R^e^s^earch^Serv^ice^b^as^ed^on^data^f^r^om^C^eⁿ^s^u^s^B^u^reau^reports^.
Th e t h i rd t r end line in Fi gure 1 looks at cases in which h ealth insurance was
actually provided b y t he father as a p ercentage of all cases in which child support was
awarded (as oppose d to just those t hat i ncluded h ealth insurance). It s hows a
relatively flat line. In other words, during t he period 1989-1999, the p ercentage of
cas es in which h ealth insurance was required t o b e p rovided b y t he father relative t o
all ca s e s i n which child support was awarded remained relatively unchanged. The
percentage was 27.1% in 1989, it jumped to 28.5% in 1991, dropped b ack to 26.1%
in 1993, rose to 27.7% in 1995 and t o 29.1% in 1997, and d ropped b ack to 27.2% in
1999. Thus, even t hough t here were some gains i n t he requirement for p rovision of
health insurance, the act ual provision of health insurance t o children living with thei r
custodial mothers d id not improve much over t he 1989-1999 period.
Table 1 provides d etailed i nformation for 1999, the m ost recent year for which
national d ata are available, on the i nclusion of the father’s health insurance i n o rders
received b y families h eaded by mothers. Although t he 1999 survey, like t he 1997,
1995, 1993, and 1991 surveys, included custodial fathers, the t able and following
discussion are focused solely on custodi al mothers. W h ile indicating t hat about 56%
of all m others have health insurance i ncluded i n t heir child support award, t he table
al so shows t hat t he probability of health insurance c o v e rage is greatly reduced for
never-married women (39%), black (42% ) and Hispanic women (42%), and women
with less schooling (i.e., h igh s chool dropouts, 36%).

Table 1. C hild Support Aw ard Status and Inclusion of
Health Insurance in C hild Support Aw ard,
by Selected Characteristics of Custodial M o thers, 1999
Supposed t o receive child support
paymentsin1999
Characteristic of Tot a l Health insurance
custodial m others (thousands) i ncl uded i n c hi l d support
Totalaward
(thousands)
Percent
Numberoftotal
(thousands ) aw arded
Current m arital status:^a
Married 2,588 1,568 1,129 62.8%
Divorced 3,760 2,448 1,753 63.2
Separated 1,329 602 361 49.4
Neve r married 3,698 1,464 692 38.7
Race/Hispani c origin:^b
White 7,858 4,621 3,189 59.9
Black 3,225 1,289 663 42.4
Hispanic 1,728 717 360 42.2
Age:
15-17 years 83 7 6 21.4
18-29 years 3,344 1,499 822 46.3
30-39 years 4,433 2,554 1,604 55.3
40 years or older 3,368 2,073 1,547 63.2
Y e ars of s chool completed:
Less than high school 2,239 888 406 35.8
graduate
High school gr aduate or 4,344 2,229 1,463 55.4
GED
Some college , no degree 2,536 1,524 1,051 61.6
Associate degree 1,013 616 411 58.8
Bachelors degree or 1,367 877 648 66.7

Supposed t o receive child support
paymentsin1999
Characteristic of Tot a l Health insurance
custodial m others (thousands) i ncl uded i n c hi l d support
Totalaward
(thousands)
Percent
Numberoftotal
(thousands ) aw arded
Number of ow n c hildren present f rom an absent f ather:
One c hild 6,527 3,065 1,978 53.7
T wo c hildren 3,367 2,118 1,425 60.7
T hree c hildren 1,099 667 425 54.7
Four children or more 507 282 150 44.0
T otal 11,499 6,133 3,978 55.6
^Source:^U^.^S^.^C^eⁿ^s^u^s^Bu^reau^.^2002.
^No^te:^C^u^s^t^o^dⁱ^al^m^o^th^ers^a^re^defⁱⁿ^e^d^a^s^w^om^en¹⁵^y^ears^aⁿ^d^older^w^ith^ch^ildren^uⁿ^d^er²¹^y^ears^o^f
^ag^e^p^res^eⁿ^t^f^r^om^abs^eⁿ^t^f^a^t^h^ers^a^s^o^f^S^priⁿ^g^2000.
^a.^Ex^clu^d^es^a^s^m^a^llⁿ^u^m^ber^o^f^c^u^r^ren^tly^wⁱ^dow^ed^w^o^m^eⁿ^w^h^o^s^e^prev^iou^s^m^a^rriag^e^en^dedⁱⁿ^d^iv^orce.
^b.^P^e^rs^on^s^o^f^H^is^panⁱ^c^o^rigⁱⁿ^m^ay^be^of^an^y^r^ace.
CSEProgramData
P ercentage of Child Support Aw ards Enf orcedThe medical support
or Modi f i ed t hat In c l ude a H eal t h I nsurance
Orderprovi sions appear to be having
an impact on the number o f
FY1991 35.3% FY1997 38.9%childreninsingle-parent
FY1992 30.0% FY1998 34.8%families with medical coverage
FY1993 29.7% FY1999 42.7%in th e i r child support orders.
FY1994 32.3% FY2000 47.0%Accordi n g t o C S E p r o g r a m d a t a,
FY1995 32.7% FY2001 49.3%which reflect welfare families
FY1996 34.2%who are automatically eligible
for CSE services and
nonwelfare families who have
applied for CSE s e r vices, 49% of child support o rders i n FY2001 included h ealth
insurance coverage, u p from 35% in FY1991. Although t h e C S E s ys tem h as been
making progress in including health insurance coverage in child support o rders, these
figures i ndicat e t hat m any children s till lack health insurance coverage.
P.L. 105-200 r e q u ired the S ecretary o f t he Department of Health and Human
S e r v i ces (HHS) t o s ubmit a report t o C ongress containing recommendations o n a
medical support i ndicator and its integratio n w i t h the n ew performance-based
incentive funding system established for the federal Chi l d Support E nforcement
program. The M edical Support Incentive W ork Group (MSIW G), which was formed

pursuant t o t his m andate, recommended i n 2000 that a m edical support p erformance
m easure b e d el ayed because of t h e l ack of rel i abl e h i s t o ri cal i n form at i o n o n m edi cal
support. Three o f t he data elements suggested by the group are now part of the d ata-
report i n g form O C S E-157 t h at st at es are requi red t o com pl et e. The t hree el em ent s
are: (1) cases where m edical support i s o rdered (includes cash m ed i c a l support
and/ or heal t h i n surance coverage); (2) cases where h eal t h i n surance s peci fi cal l y i s
o rdered; and (3) cases where h eal t h i n surance i s p rovided as o rdered. T hese data
el em ent s appear i n Table 2.
Table 2 shows t hat i n FY2001, only 5.452 million (49%) of t he 11.050 million
families with child support o rders h ad an order t hat i ncluded h ealth insurance. The
inclusion of health insurance i n child support o rders v aried considerably from s tate
to state, from a high of 100% in South C arolina and 83% in Idaho t o a low of 2.1%
in the District of C olumbia and 10% in Kansas.
Moreover, only 18% of health insurance orders act ually resulted i n h ealth
benefits. In o ther words, in 2001, only 18% of custodial families ex p ecting t o receive
health benefits for t heir children act ually did s o. Again, there was wide variation b y
st at e; i n Ohi o heal t h i n surance was provi ded as o rdered i n 86% of t h e cases t h at
included a health insurance o rder; t he comparable figu re in Vermont was 76%. At
t h e o t h er end o f t he spect rum , ni ne st at es report ed t hat l ess t han 2 % o f t he cases t h at
i n cl uded a heal t h i n surance o rder act ua lly provided health insurance coverage.
Table 2. M edical Child Support, FY2001
^Heal^th
^CSE^Heal^th^insura^nce
^CSE^c^a^s^es^cas^e^s^w^ith^insura^nce^pro^vⁱ^ded^a^s
^wⁱ^t^h^child^me^dⁱ^c^a^l^Heal^th^Heal^th^included^a^s^%o^fh^e^a^l^t^h
^suppo^rt^suppo^rt^insura^nce^insura^nce^%o^fC^S^E^insura^nce
^St^a^t^es^orders^ord^e^r^included^pro^vⁱ^ded^orders^orders
^A^l^abam^a^172,951^87,714^86,675⁵⁹⁹^50.1%^0.7%
^A^l^as^k^a^36,532^29,623^29,591^9,378^81.0^31.7
^A^rⁱ^z^on^a^140,993^51,284^50,974⁸⁰⁸^36.2¹^.6
^A^r^k^aⁿ^s^as^103,633^70,447^56,424^9,558^54.4^16.9
^C^a^lⁱ^f^ornⁱ^a¹^,409,690^1,019,147^964,951^218,067^68.5^22.6
^C^o^l^o^rado^112,463^71,958^71,951^5,960^64.0⁸^.3
^C^oⁿⁿ^ectⁱ^c^u^t^125,622^74,928^74,884^12,508^59.6^16.7
^Dⁱ^s^t^.^o^f^C^ol^u^m^bi^a^31,795^22,637⁶⁶⁰^-²^.1^0.0
^F^l^ori^d^a^391,027^94,854^78,550^2,813^20.1³^.6
^G^e^orgⁱ^a^313,807^1,710^107,208^20,043^34.2^18.7
^G^u^am^5,909^3,928^3,910⁴³⁸^66.2^11.2

^Heal^th
^CSE^Heal^th^insura^nce
^CSE^c^a^s^es^cas^e^s^w^ith^insura^nce^pro^vⁱ^ded^a^s
^wⁱ^t^h^child^me^dⁱ^c^a^l^Heal^th^Heal^th^included^a^s^%o^fh^e^a^l^t^h
^suppo^rt^suppo^rt^insura^nce^insura^nce^%o^fC^S^E^insura^nce
^St^a^t^es^orders^ord^e^r^included^pro^vⁱ^ded^orders^orders
^H^a^w^aⁱⁱ^55,424^17,853^17,801^2,385^32.1^13.4
^Idah^o^57,991^48,215^48,158^5,274^83.0^11.0
^I^llin^oⁱ^s³⁶^,³⁸⁶⁹⁶^,⁵⁷⁷⁹⁵^,⁷⁵²²⁵^,⁹²⁷²⁸^.⁵²⁷^.¹
^In^di^an^a^244,552²¹⁷^57,669⁶⁴⁴^23.6¹^.1
^Iow^a^145,054^92,601^91,964^21,098^63.4^22.9
^K^aⁿ^s^as^85,602^9,568^8,629⁷⁹¹^10.1⁹^.2
^K^eⁿ^t^u^c^k^y^204,658^74,662^68,710^3,430^33.6⁵^.0
^L^o^uⁱ^sⁱ^an^a^166,596^126,718^126,685⁷⁰²^76.0⁰^.6
^Maiⁿ^e^55,868^36,359^23,143^1,034^41.4⁴^.5
^Mary^l^aⁿ^d^211,504^96,604^96,029^37,653^45.4^39.2
^Mas^s^ach^u^s^et^t^s^166,329^40,572^40,568⁹¹⁷^24.4²^.3
^Mi^chⁱ^g^an^762,254^424,451^380,402^60,352^49.9^15.9
^Miⁿⁿ^e^s^o^t^a^180,678^131,199^101,441^36,277^56.1^35.8
^Mi^s^sⁱ^s^sⁱ^ppi^139,287^62,077^37,404^6,794^26.9^18.2
^Mi^s^s^o^u^rⁱ^294,127^207,674^204,314^24,619^69.5^12.0
^Mon^t^an^a^30,217^24,184^24,001^6,489^79.4^27.0
^N^e^bras^k^a^72,875^22,180^22,132^-^30.4⁰^.0
^N^e^v^a^da^56,635^41,117^40,284^2,142^71.1⁵^.3
^N^e^w^H^am^ps^hⁱ^re^30,497^21,065^18,209^1,698^59.7⁹^.3
^N^e^w^J^ers^e^y^267,107^147,156^147,036^41,203^55.0^28.0
^N^e^w^M^exⁱ^c^o^29,837^17,255^17,226^-^57.7⁰^.0
^N^e^w^Y^ork^661,395^280,175^267,221^-^40.4⁰^.0
^N^o^rt^h^C^arolⁱⁿ^a^303,751^183,036^179,548^56,508^59.1^31.5
^N^o^rt^h^D^ak^ot^a^24,140^22,802^19,025^7,759^78.8^40.8
^O^hⁱ^o^625,300^279,339^103,454^88,535^16.5^85.6
^O^k^l^a^h^o^m^a^94,469^75,426^72,613^-^76.9⁰^.0

^Heal^th
^CSE^Heal^th^insura^nce
^CSE^c^a^s^es^cas^e^s^w^ith^insura^nce^pro^vⁱ^ded^a^s
^wⁱ^t^h^child^me^dⁱ^c^a^l^Heal^th^Heal^th^included^a^s^%o^fh^e^a^l^t^h
^suppo^rt^suppo^rt^insura^nce^insura^nce^%o^fC^S^E^insura^nce
^St^a^t^es^orders^ord^e^r^included^pro^vⁱ^ded^orders^orders
^O^r^eg^on^161,157^118,119^118,119^26,245^73.3^22.2
^Penⁿ^s^y^l^v^aⁿⁱ^a^489,726^171,116^122,438^37,858^25.0^30.9
^Pu^ert^o^Rⁱ^co^146,368⁵¹⁴³¹⁶^0.0^37.2
^R^h^ode^Is^l^aⁿ^d^32,829^20,082^20,081^3,918^61.2^19.5
^S^o^u^t^h^C^arolⁱⁿ^a^149,464^150,088^150,081^12,531^100.4⁸^.3
^S^o^u^t^h^D^ak^ot^a^25,888^19,042^19,042^4,123^73.6^21.7
^T^eⁿⁿ^e^s^s^e^e^195,714^105,104^88,455^12,457^45.2^14.1
^T^e^x^a^s^633,327^483,489^468,772^31,752^74.0⁶^.8
^U^t^ah^63,862^57,437^4,909^21,559^70.3^48.0
^V^e^rm^on^t^21,557^9,225^9,218^7,011^42.8^76.1
^Vⁱ^r^gⁿ^I^s^l^aⁿ^d^s^------
^Vⁱ^rgⁱⁿⁱ^a^283,587^150,318^150,218^13,100^53.0⁸^.7
^Was^hⁱⁿ^g^t^on^278,674^18,355^217,606^56,012^78.1^25.7
^Wes^t^Vⁱ^rgⁱⁿⁱ^a^85,450^44,517^29,314^2,106^34.3⁷^.2
^Wi^s^c^on^sⁱⁿ^266,665^146,967^145,127^31,104^54.4^21.4
^Wy^omⁱⁿ^g^31,246^16,706^10,349^1,427^33.1^13.8
^To^t^a^l^11,049,610^5,840,197^5,452,²²⁰^976,387^49.3%^17.9%
^Source:^T^a^ble^p^repared^b^y^t^h^e^C^oⁿ^g^r^es^sⁱ^on^al^R^e^s^earch^Serv^ice^b^as^ed^on^data^f^r^om^th^e^O^f^fⁱ^ce^of
^C^hⁱ^l^d^S^u^pport^Eⁿ^f^orcem^en^t^.
SIPPData
A report p repared i n 2000 by the Urban Institute provides l ongitudinal data on
the health care coverage of children living with thei r m others (and apart from t heir
fathers). T he report i s b ased on analys is of the 1993 Survey of In come and P rogram
Partici p at i o n (SIPP), a l ongitudinal s urvey contai ning detailed i ncome and
demograph i c i nformation on a nationally repres entative s am ple of approx imately

20,000 households. Two tables from t he report are presented i n Appendix B.

Table B .1 shows t hat 37% of the child support awards o rdered in 1993 included
an award o f h ealth insurance coverage by the noncustodial father, 16% required t he
custodial parent to provide co v e r a ge , 9% m ade s ome o ther provision for m edical

c o s t s s uch as requiring the noncustodial parent to pay m edical costs d ire c t l y o r
incl uding cas h m edi cal support in the child support award. Thirt y-ei ght percent
(38%) o f child support awards o rdered in 1993 included n o p rovision for h ealth care
coverage of any k ind.
Table B . 2 e x am i n es t h e h eal t h care coverage of cust odi al chi l d ren b ased on
whether t he noncustodial father was requi red t o p rovide health care coverage for h is
dependent children. The s econd panel o f T a b le B. 2 p rovides i nformation o n t he
health care coverage stat us of custodial families i n which the fat her was ordered t o
provide health care coverage for h is dependent children. It shows t h a t 6 8 % of the
c u s t o d ial families reported receiving health care coverage from t he noncustodial
father in at least one month o f 1993, 17% re ported t he use o f t he custodial parent’s
health insurance t o p rovide health care for t h e children, 11% relied ex clusively on
Medi cai d o r M edi care, and 4 % were uni nsured. S i x t y-fi ve percent o f t he cust odi al
families reported t hat t he private coverage from t he noncus todial father or custodial
mother was valid for all 12 months of the year.
T h e a uthor of the report m ade t he following remarks regarding the cur r e n t
applicability of the 1993 findings.
T he r esults presented i n t his paper are based on data from 1993, the most r ecent
year for which information on nonresident f athers is readily available. T o what
extent have changes s ince 1993 affected nonresident f athers’ ability to provide
health care coverage? If nonresident f athers have experienced the s ame health
care coverage t rends as the overall workforce, then the f lattening out of several
health care coverage t rends since 1993 sugge s t s t h a t t he findings are still¹¹
relevant.
Although S IP P also collected information o n h ealth insuranc e c overage of
custodial children i n its 2001 topical module questionnaire , t h o s e d a t a are not yet
available.
DataSummary
The n ational C ensus Bureau data, w h i c h reflect the universe o f custodial
families, show that in 1999 about 56% of mothers awarded child support p ayments
had h ealth insurance i ncluded i n t heir child support award. It also s howed that only
49% (i .e., 49% of t h e 56%) o f cust odi al m o t h ers ex p ect i n g t o recei ve heal t h benefi t s
for t heir children actually did s o. In contr ast , t he C S E p rogram dat a, w hi ch refl ect
welfar e f amilies who are aut omatically eligible for C SE services and nonwelfare
families who have applied for CSE s ervices, s how that in FY2001 about 49% of child
s u p port awards i ncluded a health insurance o rder. Further, only 18% of h e a l t h

¹¹ Laura Wheaton, The Urban Institut e , P repared f or Office of the Assistant Secretary f or
Planning and Eva luation, U.S. Departme nt of Health and Human Services, Contract No.
HHS-100-95-0021, Nonresident Fathers: T o What Extent Do They Have Access t o
Employ m e nt-Based Health Care Coverage?, J une 2000, p. 18 of web version
[http://fatherhood.hhs.gov/ncp-health00/ report.htm] . ( Hereafter cited as Nonresident
Fathers.)

insurance o rders were p rovided as o rder ed (i.e., only 18% of custodial mothers
ex pect i n g t o recei ve heal t h benefi t s for t hei r chi l d ren act ual l y di d s o).
T h e C SE program d ata s how a l ess effective m edical support effort than the
national C ensus Bureau data. T his m ay be because noncustodial parents t hat are not
p art of the C SE program h ave m ore i ncome and are m ore able t o p rovide med i c a l
support for their children. Even so, as not ed earlier, the n ational d ata also i ndicate
t h at m u ch m o re needs t o b e accom p l i s hed w i t h regard t o est abl i s hm ent and
enforcement o f m edical support.
Establishment of Health Insurance O rder as Part of Child Support
Aw ard/Order. As noted, t he CSE p rogram data indicate t hat i n 2001, only 49% of
families with child support awards h ad a h ealth insurance o rder included as p art o f
thei r child s upport award/order. An HHS IG report rel eas ed in J une 2000 found
“child support agencies d eficient in pursuing health insurance availability...” The
report noted that CSE s taff indicat ed that while they do try t o obtai n employm ent and
health insurance i nformation p ertaining t o noncustodial parents, they believe t h e i r
primary efforts s hould b e s p e n t in obtaining cash child support p ayments.¹² Some
observers contend t hat m edical support p rovisions should b e ex p a n d e d t o require
both noncustodial and custodial parent s t o d isclose i nformation about actual and
potential p rivate hea l t h care coverage to help CSE agencies b etter and/or more
quickl y d e termine whether privat e health insurance coverage is available t o t he
dependent children. Also, during t he last s e v e ral years t here has b een a d ecl i n e i n
the number of employers that provides health insurance for thei r employees (which
is the foundation o f t he current medical child support s ys tem), and among employers
who do provide h e alth insurance, the s hare of health insurance costs borne by
em pl oyees has i ncreased.
Enforcement of Health Insurance O rder. Of perhaps m ore s i gni fi cance
is the fact that only 18% of CSE families with a health insurance order incl uded i n
their child support award actually received t he health care coverage mandated b y t he
order (2001 data). Clearly, enforcement o f t he health insurance o rder can only come
aft er t he heal t h i n surance o rder has b een es tablished. However, high er enforcement
levels are not necessarily correlated t o high e r l evel s of establishment of health
insurance coverage.
Some reas ons for t he low compliance with health insurance orders m ay be that
t h e h eal t h care coverage i s not (1) affordabl e — h eal t h ca r e cost s h ave ri s en
dram at i cal l y over t he l ast decade and t hose cost s have i n m any i n st ances been passed
on to the b eneficiary, s o t hat noncustodial parents wh o c a n no longer meet the
prem i u m f ees, co-paym ent s , d educt i b l es, and o t h er costs associated with the coverage
and m ay l et t he coverage l apse o r t erm i n at e t he coverage al t o get h er; ( 2 ) accessi bl e
— t he rise in the use of Health Maintenance Organizations to deliver health
insurance coverage has l ed to many cases in which t he dependent child is not in the
HMO service area and therefore not eligible for coverage; (3) stability — not all
workers are full-time, year-round em ployees, thus in the cases of temporary or

¹² U.S. Department of Health and Human Services, Office of Inspector Ge n eral, Medical
Insurance f or De pendents Receiving Child Support , OEI-07-97-00500, J une 2000, p. 2.

seasonal w orkers, any access t hey h ad t o heal t h care coverage woul d general l y end
when thei r employm ent ended.
Issues
To improve establishment and enforcem ent o f m edical child support, there are
a range of heal t h coverage opt i ons. General l y speaki n g for t h e l ast s everal years t he
foc u s h as been on obt ai ni ng pri v at e h eal t h care coverage ex cl usi v el y from
noncustodial parents. The ex t ent t o whi ch custodial parents work and have access
to employer-sponsored health insurance h as increased sign ificantly during t he last 20
years. Similarly, Medicaid coverage based on child poverty has also i n cr eas ed.
T o d a y, i n m any cases heal t h care coverage i s m o re accessi bl e i f i t i s b ased on t h e
custodial parent’s coverage.¹³ Moreover, over t he last several years h eal t h care cost s
have dramati c a l l y i n creased, and it can no longer be assumed t hat all employer-
sponsored health insurance i s affordable. R equiring and enforcing ex pensive h ealth
care i nsurance m ay n egat i v el y affect t h e c u s t o d i al parent and chi l d as wel l as t h e
noncustodial parent. M ost policym a k er s agree that health care coverage must be
avai l abl e, accessi bl e, a f f o r d a b l e , and st abl e. Observers st at e t hat i f t he go al i s t o
reduce t he number o f uninsured children w ith child support o rders, in some cases, t he
only way to obtain t his result will be to rely on publicly-funded h ealth care.
As i ndi cat ed by t h e d at a d i s cussed earl i er, federal l aw has not be e n f u l l y
effective i n addressing medical child support. However, two p rovisions of federal
law h ave yet to be fully implemented. P .L. 105-200 stipulated that a m edical child
support i ncentive p ayment system b e d e veloped — t hat h as not yet h appened.
Further, although t he National M edical S upport Notice was promulgated December
27, 2000 and b ecame effective o n M arch 27, 2001, as discussed b elow, only h alf o f
the s tates are using it.
The d iscussion below p rovides contex t and background to some of the i ssues
that are preventing s tates from effectivel y establishing and enforci ng medical child
support.
Sl ow Pr ogr ess i n Establ i s hi ng and E nfor ci ng M e di cal
Support
As mentioned else w h e r e i n this report, the 1984 law (P.L. 98-378) basically
requires C SE agencies to secure medical support i nformation, a n d t o s ecure and
enforce m edical support obligations whenev er health care coverage is available t o t he
noncustodial parent at a reasonable cost. R ecogn iz ing t hat s tates were m aking s low
progress in establishing and enforci ng medical support, Congress in the 1993
amendments (P.L. 103-66) sought to remove some of the b arriers to effective m edical
support enforcement. The 1993 law p rohibited d iscriminatory h ealth care coverage
practices, created “qualified m edical ch ild support o rders” to obtain coverage from

¹³ U.S. Department of Health an d Human Services, Administration f or Children and
Families, Office of Child Support Enforcement, 21 Million Children’s Health: Our Shared
Responsibility — The Medical Child Support Working Gr oup’s Report, J une 2000, p. 2-10.
(Hereafter cited as 21 Million Children’s Health.)

group health plans t hat were covered b y the Employee Retirement Income S ecurity
Act (ERIS A), and allowed employers to deduct t he costs of health insuran ce
premiums from t he em pl o yee/ o bligor’s paycheck. Even with the enactment of the
1996 welfare reform l aw (P.L. 104-193), whi ch required i nclusion of health care
coverage in all child support o rders established o r en f o r c ed b y C SE agencies, i t i s
generally agreed that the establishmen t and enf o r cement o f m edical support h as
remained inadequate.
A 1 9 9 8 l a w ( P . L. 105-200) required t he development and use o f a “National
Medical Support N otice” and also estab lished a Medical Child Support W orking
Group charged with making recommendations to overcome t he barriers t o effective
enforcement o f m edic a l support.¹⁴ The W orking Group submitted a report t o t he
S ecret ari es o f t he Depart m ent s o f H eal t h and H um an S ervi ces (HHS ) and Labor i n
J une 2000 containing 76 recommendations related t o m edical child support. These
recommendations have not been considered by Congress.
A l though s ome critics claim that much more needs t o b e accomplished with
regard to the p rovision of medical support for children receiving CS E s ervices, s ome
analys ts contend t hat t he federal government has m ade t remendo u s s t r i des. They
not e t he fol l o wi ng accom p l i shm ent s. The federal governm ent has m oved from
recoupm ent of Medicaid costs to pursuit of privat e m edical support. The federal
government has m oved from s imply petitioni ng for m edical support t o requiring that
medical support b e i ncluded i n all CSE o rd ers. The federal government has m oved
from s imply establis h i n g medical support t o requiring a uniform national m edical
support notice t hat m ust b e honored by empl oyer group health plans. They conclude
that t h e 1 9 - year period from 1984-2003 encompasses m uch p rogress i n both
establishing medical support o rders and in enforcing t hose o rders.
Some proponents advocate t he collection o f m edical support t hrou gh income
withholding. They assert that child s upport and medica l s upport should be fully
integrated and enforced primarily through i ncome withholding. They point out that
income withholding as a p ercentage of all child support collections went from about
50% righ t b efore auto m a tic income withholding was m andated i n 1994 to 65% of
collections in FY2002. T h e y contend t hat j ust as i ncome withholding has b een so
successful for cas h child support, so too could m edical support benefit from t he
mandatory use o f i ncome withholding.¹⁵ Others warn that income withholding is too
intrusive and does not account fo r c h a n ging financial circumstances. T hey also

¹⁴ T he M edical Child Support W orki ng Group, congressionally-mandated by P.L. 105-200,
included 3 0 members representing HHS and t he Departme nt of Labor (DOL), state CSE
directors, state Medicaid direct ors, employers ( including smal l business owners a nd payr oll
professionals), sponsors and admi nistrators of gr oup health plans, organizations representing
children potentially eligible for medical support, state medical child support progr ams, and
organizations representing s tate CSE progr ams.
¹⁵ Paula Roberts, Center for Law and Social Policy, Improving Health Care Coverage in the
Child Support System, Apr. 1997, p. 11-14. See a lso Anne R. Gordon, Ur ban Institute Press,
Child Support a nd Child Well-Being, Chapter 3, Implementation of t he Income Withholding
and Medical Support Provisions of the 1984 Child Support Enforcement Amendments,p.

61-92.

contend t hat t he combination o f both child support and medical support m ay ex ceed
the limits imposed by the C onsumer Credit Protection Act .¹⁶
Exami ni ng t he Heal th Car e Cover a ge of Both Par e nts
According t o federal regu lations [ 4 5 C FR 303.31(b)(1)] , i f t he custodial parent
is already p roviding satisfactory p rivat e heal t h care coverage for h ersel f a n d t he
children, stat e C SE agenci es are not required t o petition t he court or administrative
agen cy to incl ude privat e health insurance coverage that is available t o t he
noncustodial parent at reasonable cost i n n ew or modified child support o rders. This
means t hat i f t he custodial parent is bearing t he full cost of premiums, co-paym ents
a n d d eductibles — without assistance from t he noncustodial parent — t h e C S E
agency will take no action. In such cases, cash c h i l d s u pport m ay be used to pay
heal t h care cost s . In s om e cases, a chi l d m ay h ave p ri vat e heal t h care coverage but
live i n poor housing o r l ack adequate food or clothing.¹⁷ Some observers argu e t hat
health insurance s hould b e an adjunct t o, not a s ubstitute for, the noncustodial
parent’s obligatio n t o p rovide financial s upport for his o r h er child; t hey note t hat
when insurance costs are s u b t r acted fro m t he noncustodial parent’s financial
obligation, the custodial parent has l ess resources to spend i n t he best interest of the
child.¹⁸ Others argu e t hat when m edical child support i s not provided, the custodial
parents m ay not be able to oversee the m edical health of their children.
A c cording t o t he Medical Child Support W orking Group, it often i s a s s u m e d
that only t he noncustodial parent has acces s t o pri vate health insurance. It cites a
number o f s tatistics t hat affirms t his i s a fal l acy. It recom m ends t h at a n ew paradi gm
should b e ado pted in which coverage available t o both p arents is ex amined in
determining t he medical support obliga tion. Under t his paradigm, if o nly the
custodial parent has coverage, t hat coverage should b e o rdered and t he noncustodial
parent should contribute t oward t he cost of such coverage. W hen b o t h p arents are
potentially able to provide coverage, t he coverage available t hrough t he custodial
parent (with a contri bution t oward t he co st by the noncustodi al parent) s houl d
norm al l y be prefer r e d b ecause i t — (1) m o st l i k el y i s accessi bl e t o t he chi l d , (2)
involves l ess d ifficulty in claims processing for t he custodial parent, the p rovider, and
the i nsurer, and (3) minimizes the enforcem en t d i ffi cu l ties of t he CSE agency or
private attorney responsible for t he case.¹⁹

¹⁶ T he Federal Consumer Cr edit Protection Act (T itle 15 USC Sec. 1673) limits garnishment
to 50% of disposable earnings f or a noncustodi al parent who i s t he head of a household, and
60% for a noncustodial parent who i s not supporting a second family. T hese percentage s
increase by 5 percentage points, to 55% and 65% respectively, when the arrearages represent
support t hat was due more than 12 weeks before t he current pay period.
¹⁷ P a u l a R o berts, Center f or Law a nd Social Policy, Failure to Thrive: The Continuing
Poor Health of Medical Child Support, J une 2003, p. 5-6. (Hereafter c ited a s Failure to
Thrive.)
¹⁸ Daniel R. Meyer, University of Wisconsin, Madison, Institute for Research on Poverty,
Health Insurance and Child Support, Discussion Paper, DP#1042-94, Sept. 1994, p. 5.
¹⁹ 21 Million Children’s Health,p.2-19.

S o m e anal ys t s caut i o n t hat t hi s pol i cy m ay cause c o n fl i ct i f t he st at e h as t o
enforce a m edical support o rd er against t he c u s t o d i a l parent, especially if the
cust odi al parent cont e n d s t h at t h e reason t h e m edi cal obl i gat i o n was unm et was
because the noncustodial parent failed t o m ake h is or her contribution. S u ch conflict
m ay o ccur b ecause t h ere i s m uch confusi o n over whom t h e C S E at t o rney represent s .
Most cust odi al parent s b el i eve t h at t h e C S E agency represent s t h em when i n fact t h e
CSE agency represents t he state.
Accessibility of Health Care Coverage
In general, privat e health care coverage that is available t o t he custodial parent
usually is accessible t o t he child even if the p lan coverage has a limited s ervi ce area,
as is the cas e with many Health Maintenance Organizations (HMOs). However, t his
may not be the case when i t i s t he noncustodial parent whose h ealth i n surance
coverage is being u sed, particularly if that coverage is provided t hrough an HMO.²⁰
Thus, for children liv i n g far from t heir noncustodial parent, m anaged care reduces
the attractiveness o f coverage under t he noncus todial parent’s plan relative t o o ther
options for h ealth care coverage. For ex am ple, HMO coverage in California m ay be
usel ess t o a child living i n M assachusetts. Likewise, coverage available i n upstate
New York m ay be too far away to be useful to a chil d living i n New York City.
According t o one report, since m a n a g e d care i s now the norm and only 40% of
noncustodial fathers live i n t he same city or county as t heir children , t h is can be a
serious problem.²¹
Under t he Medical Child Support W o r k i n g Group’s p aradigm, when private
health care coverage is a v a i l a ble t o a child, t he CSE agency s hould consider the
accessibility of covered s ervices before it decides t o pursue t he coverage. According
to the W orking Group, chil d r e n should not be enrolled i n any plan whose
servi ces/ p rovi ders are not accessi bl e t o t hem , unl ess t he pl an can provi de fi nanci al
reimbursement for s ervices rendered b y alternate p roviders.²²
The W orking Group recommended t hat fed eral regu lat i o n s be developed t o
defi ne “acces si bl e” coverage and t hat i t b e m ade cl ear t h at coverage t h at i s not
accessible s hould not be ordered. The W orking Group reported t he following with
regard to a d efinition o f “accessible”:
Coverage is accessible i f t he covered children can obtain s ervi ces from a plan
provider with reasonable ef f o r t b y the custodial parent. When t he only health
care option available t o t he noncustodial parent is a p l a n t hat limits service
coverage to providers within a defined geographic area, the decision maker
should determi ne whether t h e child lives within the plan’s s ervi ce area. If the

²⁰ Noncustodial parents enrolled i n other managed care arrangements, s uch as a Preferred
Provider Orga niza tion ( PPO) or Point of Service ( POS), s hould be a ble t o e xtend c overage
to children livin g e l s e w h ere, since these plans allow t he use of out-of-network medical
providers. But, reliance on out-of-network medical providers usually results in higher out-
of-pocket costs and/or restricted benefits.
²¹ Failure to Thrive,p.8.
²² 21 Million Children’s Health,p.2-19.

child does n o t l i ve within the plan’s servi ce area, the decision maker should
determine whether the plan has a r eciprocal agreement t hat permits the child to
receive coverage at no gr eater cost than if the child resided i n t he plan’s service
area. T he decision maker should als o d e t e r mi n e if primary care i s available
within the l esser of 30 minutes or 30 miles of t he child’s residence. If primary
care i s not available within these constraints, the coverage s hould be deemed²³
inaccessible.
In addi t i o n , the M edical Child Support W orking Group cautioned t hat t o b e
deem ed acces s i b l e, the health care coverage al so should be stable. The W orking
Group maintained that the d ecision maker s hould base accessibility partly on whether
i t can reasonabl y b e ex p ect ed t h at t h e h eal t h care coverage wi l l rem ai n effect i v e for
at leas t one year, bas ed on the employm ent history of the parent who is to provide the
coverage. In o ther words, it is the W orking Group’s opinion that it might not always
be feas ible to pursue health insurance coverage in the cas e of parents who are
seas onal workers . S ome observers cont end that if noncustodial parents cannot
provide continuous health care coverage for their dependent children, it may b e i n t he
best i n t erest of t h e chi l d t o recei ve pr i v at e h eal t h care coverage from t he cust odi al
parent or coverage from M edicaid o r t he Stat e C hildren’s Health In surance P rogram
(SCHIP ) Under S CHIP , which was established i n 1997, low-income children m ay
be better o ff without any coverage from t he noncustodial parent, i f t hat p arent i s
unabl e t o p rovide continuous coverage because some states do not grant S CHIP
eligibility until children have been uninsured for a waiting p eriod of three or more²⁴
months.
I ncenti ve s f or Seeki ng M e di cal Suppor t
As noted earlier, the federal government provides 66% of the funding for m ost
CSE program activities, including those r elated to med i cal support. In order t o
receive any federal funding, s tates and/or local governments m ust p rovide 34% of the
funds needed to operate their C SE programs. In t he past, when C ongress wanted to
encourage act i v i t y i n an area i t consi d ered vi t al t o t he effect i v eness o f t he C S E
program, it offered federal financial participation (FFP ) at a higher than normal l evel .
Fo r ex ample, C ongress provided enhanced FFP t o encourage p at erni t y est abl i s hm ent
and automation i n t he CSE program.²⁵
The M edical Child Support W orking Gr oup contends that Congress should
provide enhanced FFP at a 90% rate for m ed ical child support activities t o encourage
states to more aggressively pursue m ed i c a l support enforcement. The W orking

²³ Ibid., p. 3-10.
²⁴ Nonresident Fathers , p. 11-12.
²⁵ T he f ed e r a l go ve rnme nt provides 90% ma tching funds for l aboratory c osts incurred i n
determining paternity. In addition, for many years t he federal government also r eimbursed
state costs of designing and implementing automated data processing and i nformation
retrieva l s ys tems at a 90% ma tch r ate. During the p eriod FY1996-FY2001, the f ederal
ma tching rate was r educed to 80% of a capped a mount. Beginning October 1, 2001 (i.e.,
FY2002), t he federal matching r ate f or CSE c omputerization was reduced back to 66%.

Group’s recommendation limits the 90% matching requirement for m edical support
to5years.
P.L. 105-200 (enacted in 1998) also required t he HHS Secretary, in consultation
with stat e C SE direct o rs and representatives of children potentially eligible for
medical support, to develop a new m edical support i ncentive m easure b ased on the
state’s effectiveness i n establishing and enforcing medical child support obligations.
The m edical support i ncentiv e was to be part of the n ew revenue-neutral
performance-based child support incentive system, established for the overall
program i n 1998. The 1998 law required t hat a report o n t his n ew incentive m easure
be submitted to Congress not later than October 1, 1999. According t o t he Hou s e
report o n t he legi slation:
Several witnesses who appeared before the Committee r eco mme n ded that we
consider including medical child support as a performance me a s u r e . After
discussion, the Committee de c i ded not to include this measure because of the
lack of information about the r eliability of state data on medical support as well
as lack of historical information a b o ut s tate performance on the measure t hat
could b e used t o estimate payments. However, because medical support i s of
central importance t o a good child support s ys tem, the Committee decided t o ask
the Secretary t o s tudy the f easibility of using medical support as a performance²⁶
measure and to report her findings t o Congress.
Pursuant to this man d a t e , t he HHS Secretary formed t he Medical Support²⁷
In centive W ork Group (MSIW G). The work group met t wice over a period of nine
months to make recommendations to the S ecret ary. The w ork group recom m ended
that the d evelopment o f t he medical suppor t i ncentive b e d elayed until 2001 so that
i t coul d obt ai n t he necessary dat a and d evel op an ap p r o p ri at e m easure. Thi s
recom m endat i o n w as i n cl uded i n t he S ecret ary’s report t o C ongress.
A reconstituted M SIWG was l ater convened and — i n S ep t e mber 2001 —
recommended t hat t he HHS Secretary not develop a medical support p erformance
meas ure for incorporation i nto t he ex isting C SE incentive payment system . Again
noting t he lack of data , t he second MSIW G recommended t hat a measure b e
developed, but not for i ncentive p ayment purposes. T o d at e, t h e HHS S ecret ary h as
not act ed on t h i s report . Hence, a recom m endation t o C ongress has not been made
and t here remains n o i ncentive p ayment for m edical support activities.

²⁶ U.S. Congress, House Committee on Ways and Means, Child Support Performance and
Incentive Act of 1998 , r eport t o accompany H.R. 3130, 105^th Cong., 2^nd sess., H.Rept. 105-

422 (Washington: GPO, 1998), p. 35.

²⁷ In the r eport t o Congress, the group was called t he M e d i c a l Support Indicator Work
Group. T he Group me t on J une 2, 1998 and a ga in on March 2-3,1999. T he HHS Secretary
submitted t he required r eport t o Congress on J une 23, 1999.

What Is M eant by “ Reasonable Cost”?
CSE agencies are required t o pursue p rivate family health coverage when ev er
it is available at reasonable cost. Federal regulations state t hat “health insurance i s
consider ed reas onable i n cost i f i t i s employm ent-related or other group health
insurance.” The definition deeming emplo ym en t -related coverage or group (e.g.,
union) health insurance policies t o b e p er se reasonabl e i n cost w as fi rst p rom u l gat ed
in 1985. It was j ustified by a 1983 study by the National C enter for Health Services
Research, which found that employers p aid 72% of the p remium cost for low-wage
employees. T he federal Office of Child Support Enforcement ( O C S E ) t hus
concluded t hat m ost employm ent-related or other group health insurance i s
inex pensive t o t he employee/noncustodi al parent. R ising h ealth care costs have
changed t he pi ct ure. R ecent research i ndi cat es t h at t h e requi red em p l o ye e
contribution for health care coverage repres ents a m uch l arger s hare of family income
for l ow-income workers. S ome d ata s uggest t h at on average, em pl oyee cont ri but i ons
to family health care coverage premiums are equal t o 45% to 52% of the t ypical cas h
child support p ayment.²⁸
Although federal regu lations (45 C FR section 302.56) require that child support
guidelines “provide for t he child(ren)’s health care needs, through health insurance
coverage or some other m e a n s , ” t h e y d o not stipulate how this is to be done. In
practice, integrating child support and medical support can be difficult. Most states
operate under t he position t hat i f t he custodial parent provides t he health care
coverage, t he cash s upport award is suppose t o i ncrease, to reflect some contribution
from t he noncustodial parent toward the cos t. If the noncustodial parent provides t he
coverage, t he cash s upport award is suppose t o d ecrease, to reflect the fact that the
noncustodial parent is subsidiz ing t he cost of health care coverage through a separate
deduction from wages toward the premium. The res ults may be problem atic in that
if the p remium associated with the h ealth care coverage is too h igh, cash s upport will
be substantially reduced, l eaving t he custodial parent without enough m oney t o t ake
care o f t he child’s food, clothing, and shelter n eeds. If cash s upport i s not adjusted
down w a r d , however, poorer noncustodial parents will pay an unreasonably h igh
portion o f t heir income as support.²⁹
Under t he Medical Child Support W orking Group ’ s p a r adigm , i n d eciding
whether t o pursue p rivate coverage, t he cost of coverage should b e considered. To
the m ax imum ex t ent possible, public dollars (through, for ex amp l e, enrollment in
Medicaid o r t he State C hildren’s Health In surance P rogram (SCHIP ) s hould b e t he
paym ent o f l ast resort. Moreover, according t o t he W o rking Group, private i nsurance
should not be ordered when its cost significantly lowers the amount of cash child
support available t o m eet the child’s basic n eeds and the child is el i g i b le for s ome
other form o f coverage.³⁰

²⁸ Ibid., p. 3-10 — 3-15.
²⁹ Ibid., p. 3-11 — 3-15.
³⁰ Ibid., p. 2-19.

According t o a Policy Interpret at i o n Questions memorandum,³¹ issued by the
Office of Child Support Enfor c e m e n t , c oncerning “reasonable cost” of medical
support, states in which t he child support o rder is established b y t he courts can enact
statutes governing t heir courts that defi ne “reasonable cost” in a w ay that the state
deems appropriate and s till meet federal requirements. Fo r ex ample, under t he Tex as
statute (Section 154.181(e) of the Tex as Fa mily Code) “reasonable cost” means t he
cost of a h ealth insurance p remium t hat does not ex ceed 10% of the responsible
parent’s monthly n et income.
In contrast, s tates t hat s et the child s upport o rder administratively t hrough t heir
CSE agencies would b e s ubject to federal l aw and regulations, which stipulate t hat
health insurance i s considered reas onable i n cost i f i t i s employm ent-related or other
group health insurance.
The W orking Group recommended t hat fed eral pol i cy b e changed t o refl ect t h e
vi ew t h at i f t h e cost o f p rovi di ng pri v at e h eal t h i n surance coverage does not ex ceed
5% of the gross income of the p arent who provides coverage, t hen t he cost should b e
deemed reasonable, regardless of whether t he child support o rder was established b y
the courts or administrativel y by t he stat e C SE agency.³²
Cooper a ti on Am ong Chi l d Suppor t, M e di c a i d, a nd SCHI P
Agencies
Even though p rivate health care coverage has advantages over public coverage
— n amely greater likelihood of full family coverage, a wider range of providers, n o³³
st i gm a, l ess t ax payer burden, and great er sat i s fact i o n w i t h vari ous aspect s o f care
— f o r t he 8.5 million children who did not have any health insurance coverage i n
2002, pu b l i c h e a l t h care coverage may n eed to be pursued if private h ealth care
coverage i s not avai l abl e o r not accessi bl e. There i s general agreem ent t hat t he C S E
agency should work m ore closely with Medi caid/SCHIP t o ensure t hat children who
have access t o p ri vat e heal t h care coverage obt ai n s uch coverage, and t h at t hose who
are eligible for publicly-subsidized health coverage are covered b y M edicai d or
SCHIP.
Al ternate Methods to Offs e t Health Insurance or Medicaid Costs.
Although focused solely on the s tate of Connecticut, a 1998 report b y t he HHS Office
of In spector General (OIG) found many noncustodial parents who were required b y
court o rder to provide health care coverage to t h ei r chi l d ren w ere unabl e t o m eet t h ei r
obl i gat i o n b ecause ei t h er t h ei r em p l o yers di d not offer h eal t h i n surance o r avai l abl e
health insurance was not reasonable i n cost. One o f t he report’s recommendations

³¹ U.S. Departmen t of Health and Human Services, Administration f or Children and
Families, Office of Child Support Enforcement, Policy Interpretation Questions, PIQ-03-

08, Medical Support i n Child Support Orders-Definition of Reasonable Cost , J uly 25, 2003.

³² 21 Million Children’s Health, p.3-11—3-15.
³³ Amy J . Davidoff, Bowen Garrett, Diane M . M akuc, a nd Matthew Schirmer, T he Urban
Institute, Children Eligible for M edicaid but Not Enrolled: How Great a Policy Concern? ,
series A, no. A-41, Sept. 2000, p. 6.

was for Connecticut to require noncustodial parents t o p ay all o r p art o f t he Medicaid
premiums for t heir dependent children. The report estimated t hat C onnecticut would
save about $11.4 million annually in combined federal and state M edicaid costs if it
required noncustodial parents t o o ffset Medicaid p remium s p a i d by the s tate on
behalf of the children o f these noncustodial parents.³⁴
Similarly, a 2003 HHS OIG report focused on North C arolina found that about
$17.4 mil l i on could h ave b een collected from t he noncustodial parents o f 30,987
chi l d ren t o p a r t i a l l y offset t h e M edi cai d c ost i ncurred b y t he state and federal
governments t o p rovide heal t h care t o t hese chi l d ren.³⁵ Although f e d e ral law does
not require noncustodial parents t o p rovi de medical support i f t he employer does not
offer heal t h insurance or t he insurance i s t oo costly, s tates have t he authority to
modify state l aws t o requi re noncustodial parents t o contribute t o t heir de p e n d ent
chi l d ren’s M edi cai d cost s .
In cases where a p arent h as access t o p ri vat e heal t h care coverage but i t i s t o o
costly, t he child may t hen be enrolled i n Medicai d, if eligible. In such cases, i t m ay
be less ex pensive for the s t a t e i f the child were enrolled i n t he privat e health care
c o v e rage. For ex ample, the noncustodi al parent’s share o f t he private h e a l t h
insurance premium might be less than what the s tate pays an HMO for the child’s
Medi cai d coverage. In t hat case, m any ex pert s b el i eve t h at i t woul d m ake s ense for
Medicai d t o pay the private h e alth coverage premium.³⁶ Federal l aw al l o ws
individuals to obtain p rivate health care coverage with a public subsidy. Speci fically,
section 1906 of the S o c i a l S ecurity Act allows state M edicaid agencies t o u se
M e d i c a i d f unds to purchase group health insurance coverage if such coverage is
avai l abl e t o a Medi cai d-eligible individual.
Closing the Gap Betw een Those E ligible f o r M e dicaid a nd Those
Enrolled. In m any cases, chi l d ren are uni nsured because pri v at e h eal t h i n surance
c o v e r age is not available t hrough either parent, and the custodial parent has n o t
enrolled t he child in the available public health care system, i.e., Medicai d or S CHIP .
One s tudy estimates t hat enrolling uninsur ed , child support-eligible children i n
Medicaid o r S CHIP could reduce t he share o f t hese children who are uninsured from
15% to 3%. A c cording to some analys ts, requiring that the child be enrolled i n
Medicaid o r S CHIP (if eligible) when p ri vate coverage is not available s hould b e a
standard part of the child support p rocess. Also, as m entioned above, consideration
could also b e given to having the noncust odial parent con t r i b u t e t o any premiums,
co-payments, or deductibles associ at ed with SCHIP coverage if the s tate in which t he
chi l d i s t o be enrol l ed h as a s eparat e S C HIP program t hat i m poses t h ese cost s . T hese

³⁴ U.S. Department of Health and Human Services, Office of Inspector General, Review of
Availability of Health Insurance f or Title IV-D Children, A-O 1-97-02506, J une 1998.
³⁵ U.S. Departme nt of Health and Human Services, Office of Inspector General , Review To
Increase the Number of Noncustodial Parent s Providing Medical Support t o Their Children
and Reduce M edicaid Costs in North Carolina, A-04-02-00013, J une 2003.
³⁶ Failure to Thrive,p.20.

types o f p rocedures might spread the cost m ore equitably b etween the p arents, and
between parents and the s tate.³⁷
If the s tate does not want to require enrollment i n publ i cly-funded m edical
programs, i t could provide information on t he availability of the program s. It has
been estimated t hat 66% of uninsured child s upport-eligible children are eligible for
Medicaid, and another 15% are eligible for S CHIP . One of the m ain reasons for t his
lack of health care coverage of children who are eligible for public health care
programs is that many parents d o not know about Medicaid a n d S C H IP o r d o not
know how to enroll their children. About one-third of the p arent s o f e ligible but
not-enrolled children reported t hat t hey h ad not heard o f M e d icaid o r S CHIP .
Another 10% had difficulty with the enrollment process. An option would be for the
CSE agency t o p rovide parents with info rmation about th ese p rograms and assist
them in the enrollment process.³⁸
The ability to move back and forth between the non cu s t o dial parent’s health
insurance plan and an alternative s ou rce o f c o verage i s an important fact or in
determining t he best so u rce of coverage for a child whose noncustodial parent has
access t o em p l o ym ent -based h eal t h care coverage on an i rregu l ar o r s easonal b asi s .
According t o one author:
T r ansitions to and f r o m M edicaid can be quite seamless, since children can
remain enrolled i n M edicaid even when t hey are also covered by t he nonresident
parent’s health care plan ( in which case, the nonresident parent’s health care plan
takes precedence). However, i f t he alternative s ource of coverage is SCHIP, then
the t ransition may not be seamless, since some state s r e q u i re a child to be
unins u r e d f or t hree or more months before gaining eligibility. Unless s ome
exemption can be made for children l osing coverage from a nonresident parent,
SCHIP-eligible children whose nonresident parent can provide o n l y i rregular
access t o employment-based health care coverage may be better off if some other
f o r m o f medical support i s r equired, such as a contribution t o t he health pl a n
premiums paid by the custodial family, or contributions toward co-payments and³⁹
deductibles.
Legi sl ati ve Ti m etabl e s f or M e di cal Suppor t Have Not Been
Met
P.L.105-200 provided for a uniform manner for state s t o inform employers
about their n eed to enroll the children o f noncustodial parents i n employer-sponsored
heal t h pl ans. It requi red t he C S E agency t o u se a s t andardi z ed “Nat i o n a l M edi cal
Support Notice” (developed b y HHS and t he Department of Labor) t o communicate
to employers t he issuance of a m edical s uppor t o r d e r. Employers are required t o
accept t he form a s a “Qualified M edical Child S upport Order” (QMCS O) under

³⁷ Ibid., p. 17.
³⁸ Ibid., p. 17-20.
³⁹ Nonresident Fathers , p. 16-17.

ERIS A.⁴⁰ An appropriately completed n ational m edical support notice i s considered
to be a QMCSO and as s uch m ust b e honored by the employer’s group health plan.
P . L. 105-200 also requires p lans sponsored by churches and s tate and l ocal
governm ent s t o p rovi de benefi t s i n accordance wi t h t h e requi rem en t s o f an
appropriately completed NMSN. The l egislation envisioned t hat all stat es would be
usin g t h e N M SN by October 1, 2001 or, at t he latest, b y t he end o f first legi slative
sessi on t o occur aft er t h at dat e , i f s t a t e l egi sl at i o n was needed. It al s o requi red
e m p l o yers t o honor any appropriately completed NMSN and send it to th e
appropriate plan administrat or within 20 busines s days. The plan administrat or has

40 days fr o m t h e d a t e o n t he NMSN to respond to the C SE agency. Finally,

em pl oyers we r e r e qui red t o not i fy t he st at e C S E agency i f t h e em p l o yee was
terminated thereby alerting t he CSE agency o f t he need to enforce m edical support
against any new employer b y i ssuing another NMSN.
A d r a f t NMSN was i ssued for public comment on November 15, 1999.
C h a n ge s w ere m ade i n response t o comments from t he Medical Child Support
W o rking Group, as well as the public. The Department of Labor and t he Department
of Health and Human S ervices adopted final regulations on December 27, 2000,
implementing t he National M edical Suppor t Notice provisions of the C hild Support
Performance and Incentive Act of 1998 (P.L. 105-20 0 ) . O n J anuary 26, 2001, the
Federal R egister published a notice t hat d el ayed t h e effect i v e d at e o f t he fi nal N MS N
regu lations until March 27, 2001.
Although C ongress required all state C SE agencies to u s e t h e NMSN once i t
was p romulgated, few states had implemented it by the t arget d ate o f October 2001.
Accordi n g t o O C S E, 37 st at es and t erri t o ri es had t o d el ay i m p l em ent at i o n o f t he
NMS N because t h ei r l egi s l at u res n eeded t o pass t h e requi red l egi s l at i on. Accordi n g
to National W omen’s Law C enter, as of September 2002, about 30 states had p assed

⁴⁰ At the s ame time t hat t he QMCSO provi sions were added t o ERISA, Congress also added
section 1908 (later change d t o s ection 1908A) t o t he Social Security Act. Section 1908A
of the SSA co nditions state eligibility for M edicaid matching f unds on the enactment of
certain specified state l aws r elating t o medical child support. Under s ection 1908A states
must enact laws under which insurers (including gr oup h e a l th plans) ma y not deny
enrollment of a child under t he health coverage of the c hild’s parent on the ground that the
child is born out of wedlock, not claime d a s a dependent on the parent’s t ax return, or not
in residence with the parent or i n t he insurer’s service area. Section 1908 also sets out rules
for s tat e s t o r e quire of employers and insurers when a parent i s ordered by a court or
admi n i s t r a t i ve a ge ncy t o provi de health coverage for a child and t he parent is eligible for
health coverage from t hat i nsurer or employer, i ncluding a provi sion which permits the
custodial parent or the s tate CSE agency t o apply f or available co ve r a ge f or the child,
without regard to open s eason restrictions. Source: Federal Register , v. 65, no. 249, Dec.

27, 2000, p. 82128.

NMSN implementation l egislation.⁴¹ Accordi n g t o t h e C e n t er on Law and S o ci al
Policy, as of April 4 , 2003, about half the s tates were not yet u sing the NMSN.⁴²
Federal l aw mandates t hat s tates h ave p rocedures under which all child support
orders are required t o i nclude a p rovisi on for t he health care coverage of the child
(section 466(a)(19) of the S ocial S ecurity Act). Federal law does not, how e v e r ,
stipulat e state use of t he NMSN in the C SE state p lan requirements o n p rovision of
heal t h care coverage.⁴³ Thus, a state t hat does not use t he NMSN is not considered
to be in noncompliance with the s tate CSE p l a n , a n d t hereby is not subject to a
f i n ancial p enalty. S ome observers cont end t hat imposing financial sanctions o n
states that d o not use t he NMSN could i ncrease its use and thereby i ncrease
enforcement o f m edical child support. Some states contend t hat t he NMSN is much
too l ong and cite the ex pense of mailing s uch a lengthy document t o a large number
of employers. Fu rther, others note t hat federal l aw does n o t requi re t h at st at es
impose financi al penalties on employers who fai l t o comply with the NMSN (stat es ,
however, can impose s uch s anctions under s tate law). According t o t he National
W o men’s Law Center, s ome s tates without re levant employer and p lan administrator
sanctions are concerned t hat t he lack of sanctions may b e an b ar r i er to successful
enforcement o f m edical child support.⁴⁴

⁴¹ National Women’s L a w C e nter, Implementing t he National Medical Support Notice:
Insights From State Experiences, Sept. 2002. (Hereafter cited as Implementing t he National
Medical Support Notice.)
⁴² Failure to Thrive, p. 14-15.
⁴³ P.L. 104-193, the 1996 welfare r eform l a w ma de revi sions to section 466(a)(19) of the
Social Security Act, including the elimi n a t i o n o f t he general reference t o t he National
Medical Support Notice. Federal l aw does provide that “in t he case i n which a noncustodial
parent provides such [health care] cove rage and c hanges employme nt, a nd the new employer
provides health care coverage, the State agency shall t ransfer notice of t he provision t o t he
employer, which notice shall operate to enroll the child in the noncustodial parent’s health
plan, unless t he noncustodial pa rent contests the notice.”
⁴⁴ Implementing t he National Medical Support Notice ,p.2-3.

Appendix A: Legislative History of
Medical Child Support P rovi sions
Just as Temporary Assistance for Needy Families (TANF) recipients must
assign their child support rights t o t he stat e, so too m ust M edicaid recipients assign
their m edical support rights t o t he state. The impetus for t he federal government
moving into the arena of financial child support was to reduce federal ex penditures
on the old Aid t o Families with Dependent Children (AFDC) entitlemen t program
(which was replaced in 1996 by the time-limited T A N F b l ock grant program).
Similarly, the impet us for t he federal government moving into the arena of medical
support for children (eligib l e f o r child support) was t o reduce federal costs o f t he
Medi cai d p rogram . T hi s s ect i o n o f t he report s ummariz es m ajor medical child
support provisions.
P.L. 95-142, M edicare- M e dicai d Anti-fraud a nd Abuse
Am endments (H.R. 3 ), Enacted October 25, 1977
The first link b etween child support and medical support came as an attempt t o
recoup the costs of Medicaid p rovided to public assistance families under Title XIX
of the S ocial S ecurity Act. J ust two years after the creation of t he CSE (i.e., IV-D of
the S o c ial S ecurity Act) program, the Medicare/Medicaid A nti-fraud and Abuse
Amendments of 1977 established a medical support en f o r c e m e n t p rogram that
allowed st at es t o requi re t h at Medi cai d appl i cant s assi gn t h e i r ri ght s t o m edi cal
support t o t he sta t e. Fu rther, in an effort to cover children with private i nsurance
instead of public programs, when available, it permitted C SE and M edicai d agencies
to enter i nto cooperative agreements to pursue m edical child support assign ed to the
state. (It s hould b e noted that act i v itie s p erformed by the C SE agency under a
cooperative agreement with the M edicaid agency m u s t b e funded b y t he Medicaid
agency.) The 1977 law also required s tate CS E agencies t o notify M edicaid agencies
when privat e family health coverage was ei t h er obtai ned or discontinued for a
Medicaid-eligible person.
P.L. 98-369, the Deficit Reduction Ac t of 1984 (H.R. 4170 ) ,
Enacted July 18, 1984
P.L. 98-369 mandated st at es t o requi re t h at Medi cai d appl i ca n t s assi gn t h ei r
righ ts to medical support t o t he state (Section 1912(a) of the S ocial S ecurity Act).
P. L. 98-378, the Chi l d Suppor t E nfor cement Amendments of
1984 (H. R. 4325), E nacted August 16, 1984
Section 1 6 o f P ublic Law 98-378, enact ed in 1984, required t he HHS Secretary
to issue regulations to require that stat e C SE agencies petit i o n for the i nclusion of
medical support as p art o f any new o r m odifi ed child support o rder whenever health
care coverage is available at “reasonable cost” to the noncustodial parent of a child
recei vi ng AFDC , M edi cai d, or fost er care b enefi t s or servi ces. A ccordi n g t o federal
regu lations, any employment-related o r o ther group coverage was considered

reasonable, under t he assumption t hat h ea lth insurance i s i nex p ensive t o the
employee/noncustodial parent.
Implementing Regulations. On October 16, 1985, the Office of Child
Support Enforcement (OCSE) published regul ations amending previous regu lations
and implementing s ection 1 6 o f P . L. 98-378. The regulations required s tate CSE
age n cies to obtain b asic medical support i nformation and provide this information
to the s tat e M e d i c aid agency. T he purpose o f m edical support enforcement i s t o
ex pand the numb e r o f children for whom privat e health insurance coverage is
obtained b y i ncreasing t he availabili t y o f t h ird p arty resources to pay for medical
care, and t hereby reduce M edi cai d cost s for both t he states and t he federal
government. If t he custodial pa r e nt does not have satisfactory health insurance
coverage, t he child support agency m ust p etition t he court or administrative authority
to include medical support i n n ew or modifi ed support o rders a n d inform the s tate
Medicaid agency o f any new o r m odified support o rd e rs t hat i nclude a m edical
support obligation. The regulations also required C SE agencies to enforce m edical
support that has been ordered by a court or administrative process. States receive
child support m atching funds at the 66% rate for required m edical support activities.
Before these 1985 regu lati o n s were i ssued, m edical support activities were
pursued by CSE agencies only under opti onal cooperative agreements with Medicaid
agencies. Some of the functions that the CSE agency may perform under a
cooperative agreement with the M edicaid agency i nclude: receiving refe r r a l s from
the M edicaid agency, locating noncustodi al parents, e s tablishing paternity,
det e rmining whether the noncustodial pare nt has a health insurance policy o r p lan
that covers the child, obtaining suffici ent i nformation about t h e h e a lth insurance
policy or plan t o permit the filing of a cl ai m with the i nsurer, filing a cl ai m with the
insurer o r t ransmitting t he necessary info r m ation t o t he Medicaid agency, securing
health insurance coverage through court or administrative order, and recovering
amounts n ecessary to reimburse medical assistance paym ents.
M o r e Regulations. On September 16, 1988, OCSE issued regu lation s
ex panding the m edical support enforcement p rovisions. These regu lations required
the C SE agency to develop criteria t o i dentify ex i sting child support cases that have
a high potential for o b t ai n i n g medical support, and t o p etition t he court o r
adm i n i s t rat i v e aut hori t y t o m odi fy support orders to incl ude m edi cal s upport for t h es e
cases even i f no ot her m odi fi cat i o n i s ant i cipated. The CSE agency also i s required
to provide the custodial parent with info rmation regarding the health i n s u rance
coverage obtained b y t he noncustodial parent for t he child. M oreover, the regulation
deleted t he condition t hat C SE agencies may s ecure health insurance coverage under
a cooperat i v e agreem ent onl y when i t wi l l not reduce t he noncust odi al parent ’s abi lity
to pay child support.

P.L. 103-66, the O mnibus Budge t Reconciliation Act of 1993
(H. R. 2264), e nacted August 10, 1993
Before late 1993, employees covered under t heir employers’ health care p lans
gen e rally could provide coverage to children only i f t he children lived with the
em pl oyee. However, as a resul t o f d i vorce proceedi n gs , em p l o yees oft en l ost cust ody
of their children but were nonetheless requi red t o p rovide their h ealth care coverage.
While the employee would be obliged to follow t he court’s directive, the employer
that s pons ored the employee’s health care plan was under no similar obligation.
Even if the court ordered the employe r t o c o n t i n ue health care coverage for t he
nonresident child of their employee, the employer would b e under n o l egal obligation
todoso.
Aware of this situation, Congress took the followin g l e gi slative action i n t he
Omnibus Budget Reconciliation Act of 1993 (P.L. 103-66):
(1) Insurers were p rohibited from d en yi ng enrollment of a child under t he health
insurance coverage of the child’s pare nt on the grounds that the child was born
out of wedlock, is not claimed as a dependent on t h e p arent ’s federal i n com e t ax
return, o r does not reside with the p arent o r i n t he insurer’s service area;
(2) Insurers and employers were required, in any case i n which a p a r e n t i s
required b y court o rder to provide health coverage for a child and t he child is
otherwise eligible for family health coverage through t he insurer: (a) t o permit
the parent, without regard to an y enrollment season restrictions, t o enroll t he
child under s uch family coverage; (b) if the parent fails to prov i d e h ealth
insurance coverage for a child, t o enrol l t he child upon application b y t he child’s
other p arent o r t he state child support or M edicaid agency; and (c) with respect
to em ployers, not to disenroll t he child unles s t here i s s a t i s fact ory written
evidence that the order is no longer in effect or the child is or will be enrolled
in comparable health coverage through another i nsurer that will take effect not
later t han t he effective dat e of t he disenrollment;
(3) Employers doing busines s i n t he stat e, if they offer health insurance and if
a court o rder is in effect, we r e r e q u i red t o withhold from t he employee’s
compensation t he employee’s s hare of premiums for health insurance and to pay
t h at share t o t he i n surer. The HHS S ecret ary m ay provi de by regu l at i o n for such
ex ceptions to this requirement (and other requirements described above that
appl y t o em p l o yers) as t he S ecret ary d et erm i n es necessary t o ensure com p l i ance
with an order, or with the limits on withholding that are s pecified in section

303(b) of the C onsumer Credit Protection Act;

(4 ) In s u rers were prohibited from imposing requirements o n a state agency
act i n g as an agent or assi gn ee of a n i n d i vi dual el i gi b l e for m edi cal assi st ance
t h at are d i fferent from requi rem ent s appl i cabl e t o an agent o r assi gn ee o f a n y
other i ndividual;
(5) Insurers were required, in the cas e o f a child who h as coverage through t he
insurer o f a noncustodial parent to: (a) provide the cu s t o d i a l p a rent with the

information necessary for t he child to obtai n benefits; (b) permit the custodial
parent (or p rovider, with the custodial parent’s approval) to submit cl aims for
covered s ervices without the approval o f t he noncustodial parent; and (c) m ake
paym ent on claims direct l y to the cust odial parent, t he provider, or the s tate
agency;and
(6) The stat e Medicai d agency was permitted t o garnish the w ages , s al ary, or
other employm ent i ncome o f, and t o w ithhold s tate tax refunds to, any person
who: (a) i s required b y court o r administrative o rder to provide health insurance
coverage t o an i ndi vi dual el i gi b l e for M edi cai d; (b) h as recei ved p aym ent from
a t hird party for the costs of medical serv ices to that individual; and (c) has not
r e i m bursed either the i ndividual o r t he provider. The amount subject t o
garnishment o r withholding is the amount required t o reimburse the s tate agency
for ex p enditures for costs o f m edical services provided under t he M e d i c a i d
program. Claims for current or past due child support t a k e p r i ority over any
cl ai m s for t he cost s o f m edi cal servi ces.
P.L. 104-193, the P ersonal Responsibility a nd Work
Opportunity Reconciliation Ac t o f 1996 (H.R. 3734), e nacted
August22,1996
Under t he 1996 welfare reform l egis l a t i on, the d efinition o f “medical child
support o rder” i n t he Employee Re tirement Income S ecurity Act (ERIS A) was
ex panded t o clarify that any j udgment, d ecree, or order t hat i s i ssued by a court o r b y
an administrative p rocess h as the force and effect of law. In a d d i t i on, the 1996
wel fare reform l aw st i pul at ed t h at al l o rders enforced by t h e s t at e C S E agency m ust
include a p rovision for h ealth care coverage. If t he noncustodial parent changes j obs
and t he new employer p rovides h ealth coverage, t he s t a t e m ust s end notice o f
coverage to the new em ployer; t he notice m ust s erve to enroll the child in the health
plan of the n ew employer. (Before enactment of P.L. 104-193, families who were not
receiving public assistance benefits could choose not to seek medical support.)
P. L. 105-200, the Chi l d Suppor t P er for m ance and I ncenti ve
Act of 1998 (H.R. 3130), enacted July 16, 1998
P.L.10 5 - 2 0 0 provided for a uniform manner for states to inform employers
about their n eed to enroll the children o f noncustodial parents i n employer-sponsored
health plans. It requir e d t h e CSE agency to u se a s t andardi z ed “Nat i onal M edi cal
Support Notice” (developed b y HHS and t he Department of Labor) t o communicate
t o e m p l oyers t he issuance of a m edical support o rder. E mployers are required t o
accept t he form as a “Qualified M edical S upport Order” under E RIS A. S tates were
required t o b egin using t he national m edical support notice i n October 2001, although
many stat es had t o del ay implementation until enactment of required s tate enabling
l e gi slation. An appropriately completed n ational medical support notice i s
considered t o b e a “ Q u alified M edical Child Support Order” and as such must be
honored by the employer’s group health plan.
P.L. 105-200 also called for the j oint e s t a b l i s hment o f a Medical Support
Working Group by the S ecret aries of HHS and Labor to identify impediments t o t he

effective enforcement o f m edical support b y s tate CSE agencies and to submit to the
S ecret ari es o f HHS and Labor a report cont aining recommendations addressing the
identified impediments.
In addition, the HHS Secret ary, in consultation with stat e C SE direct ors and
representatives of children potentially eligible for m edical support, was d irected to
devel o p a perform ance m easure b ased on t h e effect i v eness o f s t at es i n est abl i s hi ng
and enforcing medical support obligations and t o m ake recommendatio n s f o r t he
incorporation o f t he measure i n a revenue n e u t r a l m a nner i nto t he Child Support
In centive P ayment System, n o l ater than October 1 , 1999.

Appendix B : H ealth Care Cove rage
of Custodial Children — 1993
Table B .1. Provision for H ealth Care Costs in t he
Child Support Aw ard or Ag reement, 1993
Custodial f amily income level
<200%200%
P overty P overty+ Total
Families w ith a Formal Child 2,858 2,244 5,102
Support Aw ard o r Agreement
Noncustodial father to provide health 37% 38% 37%
carecoverage
Custodial family to provide health 11% 21% 16%
carecoverage
Other provi sion for health care costs 9% 9% 9%
No provision f or health care c osts 43% 32% 38%
^Source:^L^a^u^r^a^W^h^eatoⁿ^,^T^h^e^Ur^b^aⁿ^Iⁿ^s^titu^te,^N^onr^esⁱ^d^ent^F^at^her^s^:^T^o^W^hat^Ext^e^nt^D^o^T^h^ey^H^a^ve
^Acces^s^t^o^E^mployment-Ba^s^e^d^H^ealth^C^a^r^e^C^o^ver^age?^,^J^uⁿ^e^2000,^p.⁶^o^f^w^eb^v^e^rsⁱ^oⁿ
^[h^ttp://f^ath^e^rh^ood.h^h^s^.g^ov^/n^cp-^h^ealth^00/report.h^t^m^]^.
Table B .2. H ealth Care Coverage of Children
in Custodial Families in 1993
Custodial f amily income level
<200%200%
P overty P overty+ Total
Al l custodi al f amilies (thousands) 6,636 3,591 10,227
Health care c overage provi ded by: * ( 100%) ( 100%) ( 100%)
Noncustodial father 21% 30% 24%
Custodial parent 21% 61% 35%
Medicaid/Medicare only 50% 5% 35%
Uninsured8%4%6%
With private coverage entire year 23% 79% 43%
Custodial f amilies w here noncus todi al
f ather required to provide health care
coverage (thousands) 1,062 846 1,908
Health care c overage provi ded by: * ( 100%) ( 100%) ( 100%)

Custodial f amily income level
<200%200%
P overty P overty+ Total
Noncustodial father 66% 71% 68%
Custodial parent 12% 24% 17%
Medicaid/Medicare only 18% 2% 11%
Uninsured4%3%4%
With private coverage entire year 48% 87% 65%
Custodial f amilies w ith aw ard or
agreement, but f ather not required to
provide health care coverage (thousands) 1,795 1,398 3,193
Health care c overage provi ded by: * ( 100%) ( 100%) ( 100%)
Noncustodial father 15% 16% 15%
Custodial parent 26% 77% 49%
Medicaid/Medicare only 52% 3% 30%
Uninsured7%4%6%
With private coverage entire year 22% 83% 49%
No aw ard or agreement (thousands) 3,779 1,346 5,125
Health care c overage provi ded by: * ( 100%) ( 100%) ( 100%)
Noncustodial father 10% 18% 12%
Custodial parent 21% 68% 33%
Medicaid/Medicare only 59% 10% 46%
Uninsured 10% 4% 8%
With private coverage entire year 16% 69% 30%
^Source:^L^a^u^r^a^W^h^eatoⁿ^,^T^h^e^Ur^b^aⁿ^Iⁿ^s^titu^te,^N^onr^esⁱ^d^ent^F^at^her^s^:^T^o^W^hat^Ext^e^nt^D^o^T^h^ey^H^a^ve
^Acces^s^t^o^E^mploy^m^eⁿ^t^-^B^a^s^e^d^H^ealth^C^a^r^e^C^o^ver^age?^,^J^uⁿ^e^2000,^p.⁷^aⁿ^d⁸^o^f^w^eb^v^e^rsⁱ^oⁿ
^[h^ttp://f^ath^e^rh^ood.h^h^s^.g^ov^/n^cp-^h^ealth^00/report.h^t^m^]^.
^*^I^f^a^t^l^eas^t^oⁿ^e^cu^s^t^odial^ch^ild^receiv^e^s^h^ealth^care^c^ov^erag^e^f^rom^a^gⁱ^v^eⁿ^s^ou^rceⁱⁿ^a^t^l^es^t^oⁿ^e^m^oⁿ^t^h
^of^th^e^y^ear,^t^h^eⁿ^t^h^e^f^a^m^ily^is^con^s^idered^to^h^a^v^e^r^eceiv^e^d^h^ealth^care^c^ov^erag^e^f^rom^t^h^a^t^s^ou^rce.^T^h^e
^f^a^m^ily^is^placedⁱⁿ^to^th^e^f^irs^t^of^th^e^categ^ories^t^h^a^t^a^pplies^t^o^it.