CHILD SUPPORT 
ENFORCEMENT 
ABSENT PARENT

MEDICAL LIABILITY 
OFFICE OF INSPECTOR 
GENERAL 
ANAL YSIS AND 
OFFICE 
OF  INSPECTIONS 
NATIONAL PROGRAM 
INSPECTION 
SEPBE 
1987  CHILD SUPPORT ENFORCEMENT/

ABSENT PARENT

MEDICAL LIABILITY

RICHARD P. KUSSEROW

INSPECTOR GENERAL  SEPTEMBER 1987

Control #OAI-07-86-00045
 ..  ..
Table of Contents

Paqe
Executive Sumary 
. 1

In troduct ion. 

Background. . 

Objectives. . 
. 3

Methodology 
. 4

Findings 
. 6

Recommendations 
. 9

Append ix

Method Used to Determine Per-Case 
Savings. .

Savings Projections 
(Co-Pay/Deductible Applied). 
Savings Projections 
(Co-Pay/Deductible Not Applied) 
Absent Parent Profile Data. 
. 14

Statistical Data by State

. 15

Comments to Draft 
Report. . 

. 16
 EXECUTIVE SUMMARY

PURPOSE  The purpose of this inspection was 
whether the Child Support Enforcement 
 (1) to determine
absent parents to provide medical suppo(CrSEt) p rofgraom r their dis epernedqueinrt 
ing
children and 
(2) to provide an early alert to vulnerabilities

the program and poten  ings. 
tia1 Medicaid sav 
covered the three months after the effective dTahties  oifn stpheec
tion

regulations requiring medical 

support, and is the first of a

ser ies of inspections we plan to conduct involving court-
medical support. Future inspections will deal wi  ordered 
support is not included in new or amended court ortdhe wrsh ya nmded wicial

the coordination and exchange of information between State CSE 
agencies and State Medicaid agencies. 
The overall objectives of the 
inspection were to determine:

the extent to which State CSE agencies are petitioning the

courts to include medical support 

in all new and amended

court orders 

the avai1abi1 i 
ty of affordable employer-
prov ided dependent 
heal th 
insurance 
the extent to which State CSE agencies are taking steps to

enforce the health insurance coverage required by the support

and 
order 
the amount of dependent child health care expenditures the 
Medicaid program would avoid 
str ict1y  if State CSE agencies more
enforced new and existing regulations. 
BACKGROUND  For the past 
decade, Congress has expressed concern
about the responsibility of absent parents to provide medical 
support for their dependent children. 
The Medicare-Medicaid
Anti-Fraud and Abuse Amendments of 1977 (Public Law 
Section 1912 to Title XIX  95-142) added
(Grants to States for Medical

Assistance) of the Social Security Act. 
This section of the Act
permits State Medicaid agencies to establish medical support 
enforcement programs. 
Regulations published February 
11, 1980, to implement Section

1912 of the Act promoted cooperative agreements between State CSE

and Medicaid agencies to obtain third-

party liability 
information. Most  (TPL)
States elected not to enter into cooperative

agreements because the Federal funding rate 

program is lower than the amount States receifvoer  ftrhoem  Mtehdei cFaeidde
 ral 
Government for child support collections. 
Therefore regulations
were proposed by the Department of Health and Human Serv 
ices
(HHS), Off ice of Child Support Enforcement 
to " require " enforcement of medical support.( OCSE), in August 1983
 These regulations were not finalized until October 

16, 1985,

after Congress passed the 1984 CSE 
Amendments, which prov ided
that the Secretary issue regulations to require State CSE
agencies to petition for the 
inclusion of medical support as part
order. 
of any child support 
The OCSE auditors, as part of the 
i r
mandated audi t responsibili ties in fiscal year 1986 are to ensure
that State CSE agencies are 
in compliance with these regulations.
The section of these regulations relating to medical support 
which b came effective December 
2, 1985, requires State CSE

agencies to: (1) inform any individual who applies 
for State CSE

the collection of child support payments that

assistance  in 
medical support enforcement services are available; 
(2) include
medical support in new 
and amended court orders dated on or after 
December 2, 1985; (3) enforce medical support obligations,
obtaining the absent parent'
s place of employment, 
information on
whether the absent parent has a health 
so, the pol  insurance policy and, if
icy name and names of persons covered; and 
(4) share
heal th insurance information obtained on absent parents with 
State Medicaid agencies. 
These regulations were an outgrowth of a 1981 Off 

General study, "  ice of Inspector

An Assessment of Child Support Enforcement. 
METHODOLOGY  New and amended court orders established during the 
first quarter immediately following the effective date of the new
regulations 
(January-March 1986) were selected us 
ing a two-stage
sampling design. 
Nine States were selected with probability
proportional to size, and 
40 cases from each State were selected 
by simple random sampling.

MAJOR FINDINGS: 
The Medicaid program would have avoided spending over

$33 million annually 
if absent parents had their dependents

enrolled in available emp 1 oyer-prov ided health insurance. 
Over $26 million of the total Medicaid savings 

(79 percent)

would have come from cases 
in which medical support was not

included in the court order. 
All of these cases should have

contained court-
ordered medical support, but only 
did.  43 percent
In 112 of the 323 cases 
in our study 
(35 perc 2nt), the absent
parent had dependent children enrolled 
health  in employer group
insurance, including 78 cases 
(24 percent) in which
the Medicaid child was among the dependents 
enrolled.

Medicaid was paying for these enrolled dependent'

care.  s medical 
In 266 of the 323 study cases 
(82 percent), State CSE agency

case files contained the information needed to contact the

absent parent' 
s employer or the absent parent to determine
whether the employer offered group health 
insurance.  In 194 of the sample cases 
( 60 percent), the employer shown
in the CSE case file prov 
ided group health insurance to the

absent parent for dependents. 
No dependent heal th insurance
was found to be available 
cases.  in 129 (40 percent) of the sampled
Proposed regulations dated May 
27, 1987, when finalized, and
enforced would add another $77, 
annually.  343, 104 in Medicaid savings
RECOMMENDATIONS: 
The Off ice of Inspector General 
(OIG) recommends that the OCSE

make medical support enforcement a higher priority activity to

ensure State compliance with the regulations requiring that State

CSE agenc ies: 
peti tion the 
court or admin istrative author i ty, 
in all new
and amended court orders, to require the absent parent to

prov ide available health insurance for dependent 
children; 
require absent parents to notify the court or State CSE

agency when insurance coverage had been 
obtained; 
gather medical support information 

on CSE cases and submit

to the State Medicaid agency; 
request employers to advise them when an absent parent'

insurance coverage lapses; 
heal th 
improve audit procedures for and reviews of medical support

enforcement; and

finalize rules requiring identification of high priority CSE

cases and peti tions 
orders.  for inclus ion of medical support in court

RESPONSE TO DRAFT REPORT:

The Family Support Admin istra tion 
(FSA) and the Health Care
Financing Administration 
(HCFA) have agreed with these findings
and recommendations. The 
high priority.  FSA/OCSE is making medical support a
i ii
 INTRODUCTION

SA CKGROUND' 
For the past decade, Congress has expressed concern about the

responsibi1i ty of 
absent parents to provide medical support for

their dependent children. 
The Medicare-Medicaid Anti-Fraud and

Abuse Amendments of 1977 
(Public Law 95-142) added Section 1912

to Title XIX (Grants to States for Medical Assistance) of the

Act. 
Social Security 
This section of the Act permits State

Medicaid agencies to establish medical support enforcement

programs. State 
Medicaid agencies were to use the State Child

Support Enforcement 
(CSE) agencies to enforce absent parent

medical support in order to eliminate establishment of a separate 
State Medicaid medical support 
system. 
Regulations published February 
of the Act.  11, 1980, implemented Section 1912

These regulations promoted cooperative agreements
between State cSE and Medicaid agencies to obtain third-

liability  party
(TPL) information in 
an effort to reduce or eliminate
Medicaid payments where TPL was available. 
Regulations  The Code of Federal
(CFR) 42, Part 433. 136, def ines " 
any individual, entity or program that 
 third party" to mean
is or may be liable to

pay all or part of the medical cost of 
injury, disease, or

disability of an applicant or recipient.
Most States elected not to enter 

into cooperative agreements

because the rate of Federal funding for the Medicaid program 

lower than the amount States receive from the Federal Government

for child support collections. 
Therefore, the incentive is to

use available State resources to collect cash child support

payments from absent parents. 
The collection of child support

payments renders a higher return on expended State resources than

the identification of absent parent private health insurance to

reduce Medicaid expenditures. 
Due to limited participation and minimal TPL detection and 
collection under cooperative 
agreements, regulations were
proposed in August 1983 to "
require 
" enforcement of medical
support by the Department of Health and Human Services 
(HaS),
Off ice of Child Support Enforcement (OcSE). These regulations
were finalized after Congress passed the 1984 cSE Amendments

(Public Law 98-378), adding Section

452(f) to the Social Security 
Act. 
-1
 Th is section requires the Secretary of HHS to issue regulations

rRquiring State agencies administering the child support enfor

cement program to petition the courts for 

inclusion of medical

support as part of all child support orders
el ig i ble  involving Medicaid

children in the Aid to Famil 
Idren  ies wi th Dependent

Ch i  (AFDC) program whe 
ther or not reasonably pr 
insurance is available at the time the order 
 iced heal

is entered or

mod if ied. If health insurance 
is available to the absent parent

at a reasonable cost and has not been obtained at the time the

order is entered, CSE is to take steps to enforce the health

insurance coverage required by the support order and provide

insurance information to Medicaid.  this
The regulations, issued by

the Secretary on Octifob eitr  16, 1985, define " 
health insurance to be
reasonable in cost 
is employment-related or other group
health insurance. 
TheSe regulations require State cSE agencies

to: 
inform any individual who applies for State cSE assistance 
the collection of child support payments that medical support 
enforcement serv ices are available; 
include medical support in new and amended court orders dated

on or after December 
2, 1985;

enforce medical support obligations, by obtaining the absent

parent' 
s place of employment, information on whether the 
absent parent has a health insurance policy 
and, if so, the 
pol icy name and names of persons covered; and
share health insurance 
information obtained on absent parents

wi th State Medicaid agencies. 
The regulations state that 
for all cases for which an assignment

is in effect CSE must collect TPL information 

if it is available

or can be obtained and submi 
t the medical support information to

the Medicaid agency. 
The Medicaid agency is responsible for
entering the information into 
its system to prevent Medicaid from
paying for services covered by private 

insurance. The

regulations also state that, while the total amount that will be 
spent on medical care for dependent children of absent parents 
will not change sUbstantially, the financing of medical coverage 
will shift from the Medicaid program and taxpayers to
thi rd- parents,
party payors, and employers and employees who pay
premiums. 
In comments included 
in the publication of final regulations
da ted October 16, 1985, four State agencies raised the 
issue of
ot being paid for enforcement of medical support 
activities.
The reply was that the 
feas ibili ty of providing incentives to CSE
based on the avoidance of Medicaid costs will be addressed 

later, 
-2
 and that from a broad State and Federal perspective these efforts

will be as advantageous 
in terms of State and Federal savings as

pursui t of cash support. This same issue also was mentioned by

CSE staff interviewed during 
this study. One 
State cSE Director

compared the situation to a salesman who receives a commission on

refrigerators but not 
ranges, and said 
it should not surprise

anyone to find that the salesman was not selling any 
ranges. 
The
true of the cSE program. 
same thing  is  Since CSE agencies

receive Federal funds for cash child support collections but not

for obtaining medical support 

support collections.  information, their emphasis 

is 
Thus, there is little incentive for State cSE agencies to

identify TPL. 
States receive the amount they paid out
Families with Dependent Children  in Aid to

(AFDc) from the child support

collections plus an incentive payment of between 6 to 

of their cOllections, based on the cost effectiveness o1f0  tpheericre
nt

collection activity. 
Nationally in FY 
received  85, the Federal Government

33 percent of the collections and paid 
collection costs.  70 percent of the
The States received 
50 percent of the
collections and paid 30 percent of the cost. 
The OCSE audit staff are responsible to ensure State compliance with

these regulations, including the provision of medical support 

all new and amended court orders. 
The OCSE audits are required
to follow the audit standards promulgated by the Comptroller 
General of the the United States in the "
Standards for Audit of
Governmental Organizations, 
Programs, Activities and Functions.

The OCSE Audit responsibilities encompass both the 

medical support in new and amended court orders and ienncflourscieomne notf

of " 
reasonable cost" absent parent health 
insurance. 
OBJECTIVES 
The objectives of this inspection were to 
determine: 
if State CSE agency case files contained the 
information
needed to contact the absent parent'
s employer or the absent
parent to determine the availability of employer group health 
insurance for their dependents; 
the extent to which health 
insurance coverage is available

for absent parents 
' dependents through the absent parents

employers; 
the extent to which State cSE agencies are petitioning the

court or administrative authority to include medical 

support
in absent parents' child support orders dated on or after

December 2, 1985 (effective date of the 
regulations); and

-3 the amount Medicaid will save if absent parents use available

private health insurance to pay for their 

care.  dependents' medical 
This inspection  is the first in a series of inspections the OIG

plans to conduct 
involving court-ordered medical support. 
an early alert that reflects what CSE was doing to 
implemenItt the 
regulations during the first 
date.  3 months after the effective
The findings highlight specific 
areas, such as whether

current court orders contain medical  is

support, insurance 
available for absent parents 
' dependents, and Medicaid savings

would result from the use of available private 
insurance. 
Further work will be conducted to review how well the system 

working 2 years after the regulations were issued. 
will update data from this report relating to 
 The OIG

inclusion and

enforcement of court-
ordered medical support and will evaluate

the coordination and exchange of third-

State CSE agencies and Medicaid.  party information between

We will also review the imple
mentation of new regulations currently under 
consideration. 
METHODOLOGY 
There were 96, 
999 new or amended child support court orders
issued nationally between January-March 

1986, the first full

quarter following the effective date of the HHS Secretary'

regulations requiring court-ordered dependent medical suppso rnte.w

These cases were reported by OcSE on line SA of form 

Financial/Statistical Report, " for that quarter.  OCSE-56,
Nine States

329 cases from that universe (42. 
with 41, 
6 percent) were

selected with probability proportional to size. 

The States 'were
Arkansas, California, Michigan, Missouri, North Carolina, 

Ohio,

Pennsylvania, Virginia and Utah. 
Each State provided a list of cases within the designated 
quarterly time frame 
in which the absent parent had made at least
one child support payment. 
The sample was limited to cases where
the absent parent had made at least one payment, because one 
purpose of the study was to identify absent parents with health 
iinnsurasnceu covreraage navacilabele .th rough their employers. 
Absent
parents who are making support payments are more likely to 
employed and, thus, have access to employer group health
At least one child support payment had been made 

(20,  in 49. 2 percent

338 of 41, 329) of the court orders established or amended 
the quarter. 
dur ing  From these 20, 
338 court orders, a simple
random . sample of 40 cases in each of the nine States 
selected to be reviewed for collection of insurance  (360) was

information 
-4 eannd ttso . obtain Medicaid payment histories for the named depend
After selection, thirty-seven of the 
360 sample cases
still did not meet the 
inclusion criteria and were deleted from 
t(heA ca seS retviaew tpreoce ssb, r
 eakdown of casleeavs   wihnigc ha  mteott atlh eo fs e3l2e3c tciaosne sc rfiotre rrieav i
ew.
prov ided in Appendix E, page 15.

Each of the 323 State CSE agency case files which met the

selection criteria were reviewed to:

determine if court orders dated January through March 1986

required the absent parent to provide health insurance

dependent children;  for 
obtain absent parent employment information to be used
determining availabil i 
ty of affordable heal 
th insurance; and 
gather information necessary to obtain Medicaid payment 
histor ies for dependents named in support orders. 
Eighty-two percent 
(266 of 323) of the sampled State cSE case
files contained information needed to contact the absent 

employers.  parents'
These employers were contacted to determine the

availabil i ty of 
employer group health insurance for dependent

children and if the absent parent was enrolled 

The remaining 57 State cSE cases contained  a family plan.

in
inadequate or no

employer information. 
Attempts to contact absent parents

these cases proved unsuccessful. 
Medicaid payment histories were requested for 

dependents named in
the court orders where employer. group 
health insurance was

available to the absent parent for these 
dependents. 
Medicaid savings were computed based on amounts each abTsheen
 t

parent' 
s group health insurance plan would have paid

specific service paid by Medicaid. 
for each 
We did not contact Medicaid

or review their records to determine whether they had 

information

about available health insurance and procedures 
assure third party liability  in place to

determine per- payments. The method used to
case savings appears in Appendix 
A, page 10. 
The case sample  is statistically valid for the nine States

included in the study. 
Therefore, the findings have been used to

project national savings 

tuations where the absent

parents' existing employerin  thgoser oup hsei alth 

insurance should have

paid for dependent medical services rather than the Medicaid 
program. 
The savings are based only on those cases where
employer group health insurance 

is available for the absent

paying for the child' 
mparenetsd' diepcenadenlts ,c buat rMeedic.a id 

is
-5
 FINDINGS

Case breakdowns and savings related to the major findings of the 
1. 
study are reflected in Exhibit 
The exhibit reflects the
status of each of the 323 cases included in the study. 
Cases
were broken down into whether medical support was included 
court order, group dependent health insurance  in the 
was available, and

the dependents were enrolled. 
The exhibit also shows the saving

that would result from using available private health insurance

rather than Medicaid to pay for the medical care of absent

parents' 
CAP) dependents. 
Savings were divided into four groups. 
A definition of each of the savings groups follows Exhibit 
These categories also serve as the basis for discussing the 
findings and recommended corrective actions. 
EXHIBIT 
(57) 
Contact 
(72) 
Savings 
(19 )Yes  Ves (18) 
(19)  (18)
 (27)' 
SAVINGS  SAVINGS  (19)

SAVINGS
GROUP A  GROUP B  GROUP C
 SAY I NGS 
GROU P 0

11,680 *  917* 
38,270*  668 *
$3,554,211 **  632,054 **  $23,025,076** 
$3,683,  *i, 
166 
Actual S.vfngs Resul tfng fro. Sa.ple Cases

** Projected Natfonal Savfngs
 Definition of Sample Case Savinqs Groups

Private dependent group health insurance 

(HI) was available for the

dependents in each of the four savings 
categories; however, their

medical care was paid for by Medicaid. 
The four categor 
ies are: 
Medical support included in court 

order, dependents enrolled.

Medical support included in court 
enrolled.  order, dependents not

Medical support not 
enrolled.  incl ied in court order, dependents not

Medical support not included in court

enrolled.  order, dependents 
Major Findinqs 
The Medicaid program would have avoided spending $33, 
if absent parents  894, 507
in all four savings groups had their depen

dents enrolled in available employer-
provided health
insurance and Medicaid had known of and acted upon this

information. 
(See Appendix 
B, page 12). 
These savings were
found by using information contained in the 

files. 
CSE case 
Over $26 million of the 
total Medicaid savings 
would come from group C (79 percent)
and D cases which are case: 
medical  ;here
upport was not 
included in the court ordeL 
these cases should have contained court- All of 
support.  ordered medical
Savings groups A and B are cases in 
which the absent parent
was ordered to provide dependent medical support. 
These
categories account for about $7 million 
in savings and

raise questions about whether Medicaid or CSE failed to act

on this information. 
Only two of the CSE case 
files contained information that CSE

had notified Medicaid about available health insurance

coverage. We 
will examine later CSE case files and explore

the causes for not providing this 

information to Medicaid 

a later inspection. 
In 266 of the 323 study cases 
(82 percent), State CSE agency

acasbe fsilees cnontta ipneda thre einfnormta't ion 
 eeded to contact the

s employer or the absent parent to determine
whether the employer offered group heal 
unable to contact 57  th insurance. We were
(18 percent) of the absent parents or
their employers.

-7
 In 194 of the sample cases 
(60 percent), the employer shown

the CSE case file provides group health insurance to the
ain bsent parent for dependents. 
Dependent health 
insurance was
found to be unavailable in 129 
cases.  C 40 percent) of the sampled
In 112 of the 323 study cases 
C 35 percent), absent parents

had dependent children enrolled 

in their employer group 
insurance. 
heal th 
In 78 of the study cases 
C 24 percent), the Medicaid
child was already enrolled. 
In these cases, Medicaid
continued to pay for the child' 
ei ther  s medical care because
1) the CSE agency had not learned of this 
enrollment or notified Medicaid, or 
agency had failed to act upon the infCo 2r)m tahteio nMe. dicaid

In the other 34 study cases 
11 percent), the dependent

childCren) listed on the health insurance policy did not

include the Medicaid child. 
In these cases, Medicaid
could have avoided the. costs 
of the child' s medical care
if the CSE agency had enforced the Medicaid child' 
enrollment in the absent parent'
s health insurance. The
absent parent would not have incurred any additional 
cost since dependent coverage was already included 

the health insurance premiums.

Review of existing court orders containing medical support

revealed that State CSE agencies require most absent parents

to provide their dependents with private health 
insurance

coverage and to be responsible for:

all extraordinary medical, 
dental, orthodontic and

optical expenses; and

payment of deductibles, coinsurance and noncovered

serv ices.

If absent parents were held liable for all such 

expenses,

Medicaid would obtain additional savings of $7, 
095, 387.

(See Appendix C, page 13). 
Regulations proposed May 
27, 1987, when finalized, will

require State CSE agencies to identify existing CSE cases

which have a high priority for obtaining medical 

to petition the courts for inclusion of medical ssuuppppoorrtt ,
  and

these cases. One potential group of high pr 
ior i ty cases for
obtaining medical support are those where
' the 
absent parent
is making a child support payment. 
aIf galle cnasecs ywhe rew a ceolrleecti ocn 
onsidered high pr ioris  i tbye,i ng made by a State CSE

there would be 
such cases.  418, 478 
Establ ishing absent parent court- ical 
ordered med 
support for these cases would save the Medicaid program an
103. 
additional $77, 343,
Combined savings from existing and
proposed regulations would be $111,

237, 610. 
-8 RECOMMENDA TIONS

Medicaid would have saved $33, 
894, 507 nationally if OCSE ensured
that State CSE agencies enforced regulations requiring absent 
parents to enroll their dependent children 
in available,

affordable employer group health insurance. In 
35 percent of the
cases, absent parents would 
 no additional insurance cast

since dependent coverage was incaur lready part of their health

insurance. 
Therefore, the OIG recommends that OCSE make medical support

enforcement a high priority activity to ensure State compliance

wi th the regulations requiring that State CSE 
agencies:

petition the court or administrative authority 

in all new and

amended court orders to require absent parents to provide

available health insurance for their dependent 
children; 
require absent parents to notify the court or CSE when

insurance coverage has been obtained; 
gather medical support information on CSE cases and submi 

the information to the State Medicaid 

agency; 
request employers to advise them when 
an absent parent 
insurance coverage lapses;  I s
heal th 
improve audit procedures for and reviews of medical support

enforcement; and

finalize rules requiring identification of high priority CSE

cases and petitions for incl us ion 
orders.  of medical support in court
RESPONSE TO DRAFT REPORT:

The Family Support Admin istra tion 
(FSA) and the Health Care
Financing Administration
(HCFA) have agreed with these findings
and recommendations. The
FSA/OCSE is making medical support a
high priority.

-9
 APPENDIX A

METHOD USED TO DETERMINE PER-CASE SAVINGS 
Employer Contacts 
- Each absent parent' 
s employer was con
tacted to determine the availability of group health 
insurance coverage for his/her 
dependents. Where insurance
was available, various information 
(e.g., insurance company

name, plan number, deductible, covered 

etc.  services, coinsurance,

) was obtained from the employer or directly from the
indiv idual insurance 
company. 
Medicaid Payment Histories 
- Using the Medicaid payment

histories submitted by the States and the Current Procedural
Terminology 
(CPT) codes indicated on 
them, all Medicaid
billed/paid services were categorized by type of 

service. 
Listinq of Services 
- The Medicaid billed/paid ser 
ice
information was sorted to produce totals for each type of

service for each dependent 
in those cases where:

heal th insurance was available to the absent parent 
for 
dependent coverage; and 
services fell within each absent 

parents' eligibility 
da tes for insurance coverage. 
Savinqs Computations 
- Specific policy information collected

from employer and/or the insurance company was used to

calculate how much insurance would have paid for ser

billed to and paid by Medicaid. 
vices  Actual deductibles and
copayment amounts were applied to billed covered services 
shown in the following sample calculation. 
where the calculated private  In instances
insurance payment was higher
than the Medicaid allowed/paid
amount, the lower Medicaid

paid amount was used 
in the savings calculation.

A 1

10 METHOD USED TO DETERMINE PER CASE SAVINGS (CONTINUED)

Type 
Billed to  Pa i d
Serv ice  Medicaid 
Medicaid 
Off ice Vis it  $259. 
Hospi tal Inpatient 568.  $1 96 . 3 8
299.
Emergency Room 
77. 
Eye Care  43. 76
40. 
25.
$945. 
$564. 
Amount Billed to Medicaid:

$ 945.

Less Insurance Noncovered

Serv ices

- 40.  (Eye Care)

$ 905.

Less Deductible 
-250. 
$ 655.

Less 20% Copay 
-131.

SAVINGS: (Amount 
that would

have been paid by
$ 524.

pr i vate insurance) 
11
 TOTALNAT PROJ :t6 , 061 , OSB. B7$115 437 , 3BO. 02$67 462 211.$17 052.811 092 186.:$1 7 , $28 816.685 $10 690. 491 7:5$12 248 075.$29 761, 056. $33 894, 506. 2690251575E+15 35623379. 3667 11874459. 7889 . 020. 13$1 4 , 361 $53 992. 427 35. 037. 
SMP PROS  517. 10. 167.937. 837. 527. 367. 8. 227. 1 . 137. 707.  HEAN VAR STD TD ERR L 907. U 907. 
S
STATEMEAN  $44.$495. $269. $291. $B3. $111.$57. $103.$206.  $184. 
S
 D)  Bl 
TION APPLIE STATE PROJ (VR)  $91, 522. .72B 437. 675 131. 038 384. $601, 644. $963, 843. $862 416. $138 403. $505 937.  605.  722. 
ENDIX B
  PROJEC DUCTIBLE  STATE PROJ (QRn  $22, 8BO.2. 932. 109. 45 $111, 168 782. $259 596. $150 411. $240. 960. $215. 604. $34. 600. $126 484.  151, 430.  62 $20
P S E $$ 5
P G D S  65 23  3 $
A A VIN CO-PA Y I SAVINGE FOUND  40 $1, 770. 831. 40 $19,767. 40 $10 667. 40 $11,$3, 346. $4. 453. $2, 289. 143. 266.  536. $66 7
S ( MPL . 360 
A
S
NNUAL  068 23, 656 17. 368 , 560 192 7 , 656 068 336 448  1, 352 
A 8
YINa SES  517 914 342 890 798 164 767 334 612  338 
AA
PC
COURT ORDERS  464 . 857 960 651 416 264 7. 975 097 645 1 ,  329 1.
4
 
S
L
A
T
O
E  T
T
A
T
S TOTALNAT PROJ $10 362 597.$116 556.751 $77 053, 833.$20 842.258 $31 919.148 $48 675. 784 $15 608 761.:U5 , 979 . 949. 20$32. 959, 908. $40 989, 893. 2375035503E+15 3:5178168. 6604 11726056. 2201 $21 531. 700 $60 279. 256. 27 28. 61X 
1. 
SNP PROB  51 X 10. 16X 93X 83X52X 36X22X 1 . 13X 1. 70X  MEAN VAR srD rD ERR 90:1 U 90X 
s
 
5
STATEMEAN  $75.$501. $307.$331. $152. $189. $85. 1U35. $228.  $223. 
 
)
  D
S
E
APPENDIX C
 SA VINGS PROJECTION IDEDUCTIBLE NOT O-PA Y APPLI SAVINGS STATE STATE MPLE FOUND PROJ caRn PROJ (VR)  026. $39. 40 118. $156, 475. $20 057. 965 $2, 489. 40 958. 55 $11 42 861 298. 40 $12,334 09 $1 957. 339 830. 270. 40 $13 $295 272. 090. 181 098. $274 110. $1, 096 441. $7, 574. $409 791. $1, 639, 165. $3, 406. $320 760. $1, 040. 283 406. $45 143. 40 $180 573.155. $140 079. $560 318. 293. 360 $80 824 53 $5 723. 298 43 $23 893. 
C A
S
C
NNUAL  068 656 368 560 192 656 068 336 1 . 448  352 
A
AYING ASES  517 914 342 890 798 1 , 164 767 334 612  338 
PC
URT DERS  464 857 960 651 416 264 975 097 645  329 
COOR 1 . 1,
4
 
S
L
A
T
O
E  T
T
A
T
S ---- --------------------------.- .- -..- --------------------------------
- - - - 
. . . . . . . 
APPENDIX D

ABSENT PARENT 
MARITAL ST 
A TUS 
NEVER MARR I ED. . 127 
MARR I ED. 
SEPARATED. . . . 
.. 94
DIVORCED.. . . .. 
. 74 
UNKNOWN. . . . 
ABSENT PARENT 
PROFILE DATA 
AVERAGE 
AGE 
AVERAGE 
AVERAGE  AFDC 
S T (.4 T E  ABSENT PARENT CUSTOD I AL PARENT  AVERAGE
ABSENT PARENT
AGE	 GRANT AMOUNT* SUPPORT AMOUNT.

;.R 
$249. 
$99.. 
'1 I	 Z444.  $1Iy6. (il)
$446. 19  $176. . 
$261. 
;\JC	 $130. 
$235. 
tJH	 (H)  Z118.
$275. 
$124. 
()8
$369. 48  $190. 
$355. S6  $147.
3(1	
1. 12  $117. 
i1EAN 
:.32t) . 93  $144. 
*F'  CASE  AMOUNT 
14
 --------------------------------------------------------------------
-..
..' -..:."."...- ..,. .,, 
APPENDIX E

STATISTICAL DATA BY STATE 
SAMPLE  SAMPLE 
STATE  SAMPLE  CASES  CASES  INESMUPRLAONYECRE   DEPENDENT
SIZE  DROF'  REV I EWED  CONTACTED  HEAL TH DEPENDENT 
INSURANCE 
ENROLLED 
AVAILABLE 
AF,  4(1 
4(1 
4(1 

oJ 

4(1 
31)
4(1 
4(1 
-co 
40 
3(:) 
TOTAL  360 
266 
194  112 
15
 ::::
APPENDIX F

DREPAeRTMfENTe OF HrEAL TH &t. HUoMAN:  R VICE	S	 Offce of 
Child Support Enforcement
Memorandum 
Office of Child Supp rt Enforcement 
Subject: OIG Draft Report: .
Child Support Enforcement/Absent Parent 
Medical Liability, . OAI-86-07-00045 
To:	 Richard P. Kusserow 
General 
Inspec tor 
As Bob Harris, OCSE Associate Deputy Director, indicated in the
exit conference with your staff , 
we are in agreement with the 
recommendations contained in draft audit report on Absent

Parent Medical Liaibili ty 
and are making medical support a high
priority. It should be noted that two states contained in your

sample legitimately did not have legislation in place for all

or part of the audit period." I agree that it is appropriate to

include them in your projections, but recomend that the final 
report acknowledge that implementation of medical support

states. 
legislation had not yet occurred in these  California 
enacted its legislation on August 26, 1986 and imlemented it
10, 1987. 
on March - Pennsylvania enacted its legislation on 
October 18, 1985, and implemented it on January 28, 1986,

during the audit period, and within the period required by

Federal s 
ta tu te . 
I look forward to the resul ts of the second part of your study

to be done next year focusing on medical support ordered .
but 
not pursued. The Office of Child Support Enforcement bas begun

discussions with its counterparts in the Health Car.e Financing
Administration to address specific areas for review in that

area. We will share the ideas which result from these

discussions for your use in planning your study. 
n t 
Thank you for the opportunity	
yne A. Stanton

16
 '! 
Health Care
DEPARTMENT OF HEALTH &. HUMAN SERVICES  Financing Administration 
Memorandum 
7 19 
/I 2 
Date  Adto 
L. 
Wi1Hmn  Ro, M.
From 
Dr Re: -Ch Surt 
LOIGii lty, a 0A- Enorct/Abent Pat Meca
Subject 
Inr  86-Q7-00045
Office of 
th 
ha revew  ve intete 
Wfie ngs.  the OIG drt rert an are  in th
reltivey Aslmth gsha stlhe u,c octlu hsiones ar e is clea incatoion nd attha td erive fra' a
do  rrre 
chd  enorcet  shoud be
by Stte  thgh  agenies to identify an enorce
abent paents. 
IIca 
st 
We wi to ncoc uthct  th. diata  collece tnhoaugrht t h  relec
acvittiehs   8Ut 
fir 
rrnt  by  agencies during the
thil: op efoa::c  wrooefd i eIclhwde  n ttahtwi iorthne t tohs f p thasea gnee  oref tasiti toa nn . eWxei ewnocde.
to  th 
Wae: uct  of 
stuo n ctor he we th  OIG  ywehc ha fwtiel  tbhe
reemts  rki tw 
were isymte is
lE!te.
Fig 
Stf 
Ch SfrU th  Heth Ca  Apdlatrt ion an 
Enorcet  coctt he Office of
(CC) ar  to 
mreeecwa  isn uFi carp Yeretal 1 s98.8 t o m:to Sttep' riIolesm  tatijoiont n opfrogLam 
in deopin  otobs reteW  we a trh i n the  wpoirf  wcl.oe kyi w titha OC
State. We 
into coiidnettieotne t h OIG  in deoping ou 
wods bte.    in  avale Aflrsao,  we
th  any ad tian data 
OIG on
su 
reticn  na 
We  th  tht LtLhlC uda.tion  by OIG,s puatc eunlyo rtcht 
pernorotyr ta,c ttvhit y. Th gCC macr metcaa es tahev ei awisi  on meca Strta high
'l  be rezed.

rrre 
th OQrtty  th dr rep.

yo for 
on 
to 
17