Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
CLIENT COOPERATION WITH 
CHILD SUPPORT ENFORCEMENT 
Local Staff Experiences 
With Medicaid-Only Clients 
JUNE GIBBS BROWN 
Inspector General 
APRIL 2000 
OEI-06-98-00045  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is 
to protect the integrity of the Department of Health and Human Services programs as well as 
the health and welfare of beneficiaries served by them.  This statutory mission is carried out 
through a nationwide program of audits, investigations, inspections, sanctions, and fraud 
alerts.  The Inspector General informs the Secretary of program and management problems 
and recommends legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public. 
The inspection reports provide findings and recommendations on the efficiency, vulnerability, 
and effectiveness of departmental programs. 
OEI's Region VI prepared this report under the direction of Chester B. Slaughter, Regional 
Inspector General and Judith V. Tyler, Deputy Regional Inspector General. 
Principal OEI staff included: 
DALLAS  HEADQUARTERS 
Blaine Collins
 Alan Levine, Program Specialist 
Ruth Ann Dorrill
 Joan Richardson, Program Specialist 
Marnette Robertson
 Linda Hall 
Clark Thomas, Ph.D.

Nancy Watts

Lisa White

FIELD OFFICES 
Lucille Cop 
Vincent Greiber 
Ianna Kachoris 
Thomas Purvis 
Graham Rawsthorn 
To obtain copies of this report, please call the Dallas Regional Office at 214-767-3310. 
Reports are also available on the World Wide Web at our home page address: 
http://www.dhhs.gov/progorg/oei  June Gibbs Brown /s/ 
Inspector General 
OIG Final Report:  Client Cooperation with Child Support Enforcement: Local Staff 
Experiences With Medicaid-Only Clients, OEI-06-98-00045 
Olivia A. Golden 
Assistant Secretary for 
Children and Families 
We recently completed a series of reports which discuss the cooperation of Temporary 
Assistance for Needy Families (TANF) cash assistance clients with child support 
enforcement.  During this inspection, we also obtained limited information about cooperation 
from custodial parents who receive Medicaid coverage only.  Although we did not conduct a 
thorough review of this issue, the data that we did gather reveals a number of concerns which 
our State and local government respondents raised regarding gaining cooperation from these 
Medicaid-only clients. 
SUMMARY 
Workers in some child support and public assistance offices observed that the proportion of 
clients in their caseload who only receive Medicaid is increasing.  However, a number of 
workers, as well as clients, do not understand that Medicaid clients must cooperate with child 
support enforcement.  Additionally, it appears that sanctions often are not applied when 
Medicaid-only clients do not cooperate.  Some workers also report they believe that simply 
removing a custodial parents Medicaid eligibility is not an effective tool to encourage 
cooperation, reasoning that as long as their children are covered by Medicaid, parents may 
willingly forego their own medical insurance benefits rather than cooperate with child support 
enforcement.  Finally, local child support managers and workers expressed concern that being 
held accountable for large numbers of unresolved Medicaid cases could have an adverse 
effect on their performance measures and budgets. 
We are aware that the Secretary has formed the Medical Child Support Working Group to 
study and provide recommendations about how to improve the enforcement of medical 
support obligations for children.  We call these issues to your attention as your agency 
continues to develop and refine policy affecting this population. 
1
 BACKGROUND 
The Personal Responsibility and Work Opportunity Reconciliation Act removed the automatic 
link between eligibility for Medicaid and cash assistance, allowing families to qualify for 
Medicaid even if they do not receive cash assistance under TANF.  States may also expand 
Medicaid coverage to additional low-income families who do not qualify for cash assistance. 
Additionally, custodial parents who qualify for cash assistance but choose not to apply because 
they do not want to use their time-limited eligibility can still be assured of Medicaid coverage. 
Federal law continues to require that custodial parents must cooperate with the child support 
enforcement agency as a condition of eligibility for Medicaid and the State Childrens Health 
Insurance Program (SCHIP) when SCHIP is implemented as an expansion of a States 
Medicaid program.  This cooperation may help enforcement when noncustodial parents are 
ordered to provide their children with private health insurance.  Medicaid clients who fail to 
cooperate with child support enforcement, unless exempted for good cause, can be penalized 
through the loss of eligibility for Medicaid coverage, although Medicaid coverage of dependent 
children and women who are pregnant must continue even when clients do not cooperate.  The 
final determination of whether a client has cooperated is made in the child support agency. 
Medicaid-only clients may elect, but are not required, to receive assistance from the child 
support agency in establishing and collecting monetary support.  Clients are expected to notify 
the agency if they do not desire this service.  Regardless of whether a client accepts the child 
support agencys help in pursuing cash support, these medical assistance cases are included in 
child support enforcement caseloads, potentially affecting Federal funding calculations. 
METHODOLOGY 
For our inspection of TANF cash assistance client cooperation, we gathered information from 
local child support and public assistance offices.  Managers and administrators from 99 local 
child support offices and 103 local public assistance offices in six focus States - California, 
Georgia, Illinois, New Jersey, Texas and Virginia - returned mail surveys regarding 
cooperation policies, practices, and improvement strategies.  We also reviewed agency 
documents including client cooperation policy statements, standardized forms, examples of 
correspondence with clients and other agencies, outreach materials, and other related 
documents.  Additionally, we made site visits to each of the six focus States.  During the visits, 
we conducted interviews with approximately 180 managers and caseworkers at local public 
assistance and child support agency offices.  At almost all offices, we interviewed one or more 
managers, then separately interviewed two or more caseworkers experienced in client 
cooperation issues.  These respondents provided detailed information about how cooperation 
policies are implemented, as well as the effect of cooperation requirements on office 
operations, staff, and clients.  Finally, we conducted telephone interviews of administrators 
from each States child support enforcement agency and the agency responsible for each 
States cash assistance program. 
2
 The primary purpose of this inspection was to learn more about State policies and practices 
related to cooperation of custodial parents who receive cash assistance under TANF. 
However, we included questions about Medicaid-only clients in our survey instruments and on-
site interviews.  The information we present below is a product of these surveys and the 
interviews we conducted with managers and front line workers in local public assistance and 
child support offices. 
PROCESS and PRACTICES 
#	 Some child support workers we interviewed report a noticeable change in their 
case-mix and workload.  According to one child support worker, Since welfare 
reform the TANF rolls have dropped, but the medical assistance [rolls] have 
increased.  Medicaid-only cases still must cooperate. A child support supervisor also 
reports, It has changed the caseload.  We are working on more Medicaid-only clients 
and fewer welfare clients.  Twenty percent of child support offices who responded to 
our survey report that at least half of the custodial parents in their caseload are 
Medicaid-only cases.  They did not distinguish between clients who are also eligible for, 
but not receiving, TANF assistance and those who qualify only for Medicaid. 
##	 Staff in focus States employ standardized forms to inform Medicaid-only clients 
of their obligation to cooperate with child support enforcement.  These forms are 
typically mailed to clients whose medical support continues after their TANF case is 
closed, and are also presented to new clients as they apply for Medicaid benefits. 
Applicants and clients in our focus States must typically sign a statement indicating 
they have read and understand the cooperation requirements.  The following language 
is representative of these forms: 
Our records indicate that members of your family are receiving 
Medical Assistance Only.  We will be taking appropriate action 
to obtain and enforce medical insurance coverage for these 
child(ren), if such coverage is available to the non-custodial 
parent at reasonable cost.  This includes establishing paternity if 
necessary.  Your cooperation in establishing paternity and/or in 
obtaining health insurance for your child(ren) is required. 
I understand that as a condition of eligibility for Medicaid, I 
must cooperate with the Division of Child Support Enforcement 
in establishing paternity and medical support. 
3
 ##	 Medicaid-only clients can choose not to accept the assistance of the child support 
agency for establishing and enforcing cash support orders.  The forms that clients 
receive notifying them of their cooperation obligations also typically inform them that 
they will receive services related to cash support orders unless they specifically request 
medical support enforcement only.  Staff perceive that some Medicaid-only clients 
choose not to pursue cash support through the child support enforcement agency for a 
variety of reasons.  These include informal support arrangements with the noncustodial 
parent and reluctance to involve the father in the life of the child.  Additionally, staff 
indicate clients may be confused by the choice not to pursue cash support, and may not 
understand that they still must cooperate for purposes of medical support.  Staff report 
that some clients who refuse cash support enforcement services often fail to show up 
for appointments, return phone calls, respond to notices from the child support agency, 
or provide necessary information.  One child support worker explains, The ones that 
are just on Medicaid, they think they can get out of cooperating by only covering the 
child.  They sign a form saying they dont want to request our services.  But they dont 
read the whole letter because it says that we are going to pursue medical support. 
They dont understand that we have to establish paternity before we can establish 
medical support.  And they dont want to have paternity established. 
#	 Child support enforcement workers say they often encourage Medicaid-only 
clients to pursue cash support as well as medical support.  Several workers told us 
they encourage custodial parents to pursue child support in addition to medical 
support.  For example a local office manager explains, Even if they are not interested 
in the order of child support, if they are receiving Medicaid-only . . . they've got an 
option.  They don't have to receive child support payments from the noncustodial 
parent, but we try to point out the benefits of establishing paternity, and as long as 
we're going to do the order for medical support anyway, we might as well do the order 
for child support.  Another worker told us, [With Medicaid-only cases] the main 
thing I want to know is if they want us to collect child support too.  If she never 
answers me, I just go after both. 
CONCERNS 
The possible change in case-mix reported by some local staff could create a number of 
concerns for State child support and public assistance agencies.  Workers appear to face a 
greater challenge in gaining the cooperation of Medicaid-only clients than cash grant recipients, 
due to misunderstanding and lack of effective sanctions.  Following are concerns and issues 
which local staff raised during our study. 
4
 CLIENT ISSUES 
#	 Child support staff report that while many Medicaid-only clients readily 
cooperate, some choose not to provide information for the same reasons as TANF 
clients.  In cooperating, these clients provide whatever information they have, keep 
appointments and submit to genetic testing.  According to two child support workers 
we interviewed, If the mother wants to pursue child support, she is extremely 
cooperative.  Even if she does not want support right now, we establish paternity, 
which helps, because in the near future she can come back in and say I want full 
child support enforcement services.  Most of these are working moms where the 
employer does not provide medical coverage. Others want us to go after medical 
and cash support right away.  Most Medicaid-only clients are working, and have 
income, so they just want Medicaid because their employer doesnt offer 
[insurance]. 
Staff suggest, however, that some clients resist State involvement in their lives.  In the 
experience of one child support worker,  We have a lot we are getting medical service 
for and they dont cooperate and they dont want any services at all from us. 
Another child support worker suggests custodial parents do not want to jeopardize 
informal arrangements they may have with an absent parent, [Sometimes] they've 
signed the child up for Medicaid and the parents have worked out something that 
works for them as far as the child support is concerned, and they don't want us 
messing with it.  Other clients wish to avoid contact between the child and 
noncustodial parent, as one child support worker explains,  They'll close their case 
just to keep us out of it, because they are afraid that once we get involved that it gives 
that man a right to come get that child. 
#	 Many child support and public assistance staff do not believe that removing 
custodial parents Medicaid coverage is an effective tool to encourage 
cooperation.  Staff report that few sanctioned clients return to either the child support 
or public assistance office to provide information once they have received notice that 
they have lost Medicaid coverage.  A number of workers speculate that because the 
effect of this sanction is not felt immediately, it does not provide the same incentive to 
cooperate that the loss of a portion of the cash grant does for cash assistance clients. 
According to some staff, clients may understand the need for their children to have 
Medicaid coverage but discount the value for themselves.  Realizing that children 
cannot lose their Medicaid coverage regardless of a custodial parents failure to 
cooperate, one public assistance supervisor told us, They have absolutely no intention 
to cooperate.  You have to hit them in the pocketbook.   A child support manager 
also says, Unless money benefits are involved, I don't think sanctions work well to 
encourage Medicaid clients to cooperate. 
5
 STAFF ISSUES 
##	 Staff in many local offices surveyed appear not to understand that cooperation is 
a condition of Medicaid eligibility.  Thirty-one percent of child support and 25 
percent of public assistance respondents erroneously reported that a custodial parent 
cannot lose Medicaid benefits for failure to cooperate.  A few others responded that 
they did not know whether a client could lose coverage.  A comment from one worker 
typifies the misconception that because a child cannot lose Medicaid coverage, there 
can be no sanction,  It is mostly Medicaid cases that we get, and we really can't take 
an action on a child on a Medicaid case anyway.  So, we just file them away and we 
send something back saying cannot sanction, Medicaid case.  And we let child 
support know we got it but we can't do  anything about it.  I personally think it is a 
waste of time that they send them over here, because we can't do anything about it. 
#	 Local child support staff in focus States report Medicaid-only clients are 
sometimes not sanctioned for failing to cooperate.  Of the child support enforcement 
offices responding that noncooperative clients can be sanctioned, 51 percent report 
that, in their experience, Medicaid-only clients lose their coverage less than half the 
time, and 22 percent report that clients are never sanctioned.  Public assistance 
respondents agree, with 52 percent indicating that sanctions occur less than half the 
time, five percent reporting that noncooperative Medicaid-only clients are never 
sanctioned.  One child support worker confirms in an interview that the public 
assistance agency frequently does not sanction noncooperative clients, One of our 
major drawbacks is with Medicaid-only clients.  The woman may or may not be 
removed from Medicaid.  Quite often she's not because [the public assistance agency] 
views the sanction only as reducing the welfare grant, not as reducing Medicaid. 
They'll send back things and say she's on Medicaid, I can't sanction her.  Well [they] 
could. You could take her off Medicaid.  They don't do it all the time. 
#  Some child support workers report they are often frustrated when they get little 
cooperation from Medicaid-only clients.  Medicaid-only cases may be difficult to 
resolve because workers may have little initial information about the noncustodial 
parent, and experience difficulty persuading custodial parents to cooperate.  However, 
workers are often expected to make much the same effort as with cash assistance cases. 
A child support worker says, [It is a burden] because we're required, our regulations 
state that, even though it's Medicaid you have to send out an appointment [request]. 
It's a waste of time.  If theyre not going to do anything, I don't think we should have 
to go through the procedures.  I think we should just close it, because they are not 
going to respond. 
6
 ##	 Some child support managers are concerned that large numbers of Medicaid-only 
cases in their caseloads could adversely impact State agency and local office 
performance measures and budgets.  Federal funding to State child support agencies 
is based in part on State caseload measures.  While Medicaid-only cases are a part of 
this calculation, local managers in focus States argue that they are the most difficult to 
resolve and the most resource intensive. Managers report that staff are most likely to 
work the child support cases for which they have the most information and Medicaid-
only cases often do not fall into that category.  According to a child support manager, 
To tell the truth, Medicaid-only cases tend to be a second priority to our regular 
caseloads.  The collections are first.  [But we are also] measured on Medicaid-only 
cases.  It's a Federal guideline to meet percentages. 
#	 Some managers and workers are also concerned that, while they have fewer tools 
to encourage cooperation, employee evaluations are based in part on the number 
of cases they successfully resolve.  When the proportion of Medicaid-only cases 
increases in workers caseloads, they worry that their overall case disposition rates will 
decline as they spend more time on what they perceive as more difficult cases.  One 
public assistance worker explains, There is little incentive for the Medicaid-only 
cases to give us information and yet they still add to our caseload.  We have to work 
these cases regardless and we get docked for not having a better [success] rate. A 
child support worker agrees,  [Medicaid-only cases] increased our caseload 
considerably.  Without an increase in staffing, it increased our backlog.  We count the 
backlog in our office every month. 
7
 OPPORTUNITIES FOR IMPROVEMENT 
Our findings highlight a number of potential concerns regarding Medicaid-only client 
cooperation with child support enforcement.  We believe it will be useful to consider these 
findings along with the findings and recommendations of the Secretary's Medical Child Support 
Working Group. 
Further study is warranted before developing specific corrective action, but our limited 
research led us to a number of potential solutions.  Summarily, encouraging Medicaid-only 
client cooperation appears to depend primarily on ensuring staff and client understanding, and 
promoting use of appropriate sanctions.  To address problems of workers not understanding or 
enforcing the requirement that Medicaid-only clients cooperate with child support 
enforcement, the Administration for Children and Families (ACF) may, in collaboration with 
the Health Care Financing Administration, wish to: 
Provide additional technical assistance and encouragement to State and local partners 
to provide additional training to ensure that agency workers and clients understand 
their responsibilities and expectations under existing policy, and 
Continue to develop new policy or refine and issue promising pending rules which 
encourage collaboration between child support enforcement and those agencies 
responsible for cash and medical assistance to ensure that as many children as possible 
continue to receive or obtain appropriate medical coverage. 
To address problems with caseload management and performance indicators, ACF may 
consider further evaluation of staff and program performance structures, and revision of 
Medicaid-only case closure criteria. 
AGENCY COMMENTS 
The ACF agreed to help States with our suggestion of ensuring that agency workers and 
clients understand their expectations and responsibilities under existing policy.  They also plan 
to consider new policies when the Medical Child Support Working Group issues its 
recommendations this Spring. 
The ACF provided several general and technical comments which we have addressed in the 
report as appropriate.  The ACF comments are provided in their entirety in Appendix A. 
8
 APPENDIX A

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