Most Americans view health care for their children and for themselves as one of their topconcerns. The adverse consequences of going without health insurance may include unmet healthand dental needs, lower receipt of preventive services, avoidable hospitalizations, increasedlikelihood of receiving expensive emergency room care, and reduced likelihood that the doctor isfamiliar with the patient's medical history. From a public health perspective, early and frequentmonitoring of children's health is a key component to ensuring the appropriate growth and healthydevelopment of children. From a family perspective, health insurance coverage greatly reducesparental financial and emotional stress. Medical child support benefits families by increasing theincidence of noncustodial parents who obtain private health insurance coverage for their dependentchildren. With medical child support, Congress found a way to make noncustodial parentsresponsible for their children and lessen taxpayer burden by shifting costs from the taxpayers backto the noncustodial parents. Since 1977, Congress has tried to offset some of the costs associated with the Medicaid program by allowing states to require Medicaid recipients to assign their child support rights to thestate and allowing the state to pursue reimbursement of the cost of Medicaid benefits provided to thechild from the child's noncustodial parent (in 1984 mandatory assignment became law). Since 1984,Congress has tried to increase provision of private health care coverage for children whosenoncustodial parent has access to employer-related or group health insurance that is provided at areasonable cost. This is seen as a way to make noncustodial parents responsible for their childrenand lessen taxpayer burden by shifting costs from the taxpayers back to the noncustodial parents. For a detailed legislative history, see Appendix A . In 1984, federal law required that state Child Support Enforcement (CSE) agencies petition for the inclusion of medical support as part of any child support order whenever health care coverageis available to the noncustodial parent at reasonable cost. A 1993 amendment to the EmployeeRetirement Income Security Act (ERISA) required employer-sponsored group health plans to extendhealth care coverage to the children of a parent/employee who is divorced, separated, or nevermarried when ordered to do so by the state CSE agency via a Qualified Medical Child Support Order(QMCSO). The 1996 welfare reform law further strengthened medical support by stipulating thatall orders enforced by the state CSE agency must include a provision for health care coverage. (1) The1996 law also directed the CSE agency to notify the noncustodial parent's employer of theemployee's medical child support obligation. To help obtain health care coverage for children, a1998 law authorized the creation of the National Medical Support Notice (NMSN), a standardizedform, that is the exclusive document which must be used by all state CSE agencies. Anappropriately completed NMSN is considered to be a "Qualified Medical Child Support Order," andas such must be honored by the noncustodial parent's employer's group health plan. The reader should recognize that efforts to improve the establishment and enforcement of medical child support need to be viewed in the current context of high health care costs, a declinein employer-provided health insurance coverage (which is the foundation of the current medical childsupport system), an increase in the share of health insurance costs borne by employees, and a largenumber of children who are uninsured. Moreover, cash support and medical support are not alwayscompatible. For example, if premiums, co-payments, and deductibles of noncustodial parents rise,fairness might suggest that the cash child support payment of noncustodial parents be reduced toreflect payment of additional medical costs. The result, however, would be that custodial parentswould have less income to provide for the basic food, clothing, and shelter needs of their dependentchildren; conversely, if medical support is not available, the family will undoubtedly face direeconomic circumstances if a child becomes seriously ill. The public and policymakers generally agree that establishment and enforcement of medical support, where it is available on reasonable terms, promotes family responsibility, improveschildren's access to health care, and usually saves federal and state dollars. This report provides alegislative history of medical support provisions in the CSE program, describes current policy withrespect to medical child support, examines data on medical child support, and discusses some of theissues related to medical child support. Federal law mandates that states have procedures under which all child support orders arerequired to include a provision for the health care coverage of the child (section 466(a)(19) of theSocial Security Act). Medical support is the legal provision of payment of medical, dental,prescription, and other health care expenses for dependent children by the noncustodial parent. Itcan include provisions to cover health insurance costs as well as cash payments for unreimbursedmedical expenses. The requirement for medical child support is a part of the child support order,and it only pertains to the parent's dependent children. The reader should note that states canestablish child support orders (and thereby medical child support orders) either by a judicial oradministrative process (i.e., through the state courts or through the state CSE agencies). Activitiesundertaken by the state CSE agencies to establish and enforce medical support are eligible for federalreimbursement at the general CSE matching rate of 66%. (2) Medical support can take several forms. The noncustodial parent may be ordered to: (1) provide health insurance if available through his or her employer, (2) pay for private health insurance(health care coverage) premiums or reimburse the custodial parent for all or a portion of the costsof health insurance obtained by the custodial parent for the child, or (3) pay additional amounts tocover some or all of ongoing medical bills as reimbursement for uninsured medical costs. (3) PDFversion Congress has realized for many years that medical support enforcement activities need to bestrengthened. Congress recognized early in the implementation of the CSE program that manynoncustodial parents had private health insurance coverage available through employers, unions orother groups and that such coverage could be extended when available at reasonable cost to providefor dependents' medical expenses. The medical child support provisions benefit families byincreasing the incidence of noncustodial parents who obtain health insurance coverage for theirdependent children. Moreover, the medical child support provisions result in cost savings to statesand the federal governments by reducing Medicaid expenditures when such health care insuranceis available to families who are eligible for Medicaid services. (4) According to federal regulations (45 CFR 303.31), for both families who have assigned their medical support rights to the state and families who have applied for CSE services, the CSE agencymust: (1) Petition the court or administrative authority to include in the child support order health insurance that is available to the noncustodial parent at reasonable cost in new or modified childsupport orders, unless the child has satisfactory health insurance other than Medicaid; (2) Petition the court or administrative authority to include medical support whether or not --(a) health insurance at reasonable cost is actually available to the noncustodial parent at the timethe order is entered; or (b) modification of current coverage to include the child(ren) in questionis immediately possible; (3) Establish written criteria to identify cases not included under the previous two provisionswhere there is a high potential for obtaining medical support based on -- (a) evidence thathealth insurance may be available to the noncustodial parent at a reasonable cost, and (b) facts,as defined by state law, regulation, procedure, or other directive, which are sufficient to warrantmodification of the existing support order to include health insurance coverage for a dependentchild(ren); (4) Petition the court or administrative authority to modify child support orders for cases thatare likely to have access to health insurance to include medical support in the form of healthinsurance coverage; (5) Provide the custodial parent with information pertaining to the health insurance policywhich has been secured for the dependent child(ren); (6) Inform the Medicaid agency when a new or modified court or administrative order for childsupport includes medical support and provide specific information to the Medicaid agencywhen the information is available; (7) If health insurance is available to the noncustodial parent at reasonable cost and has notbeen obtained at the time the order is entered, take steps to enforce the health insurancecoverage required by the support order and provide the Medicaid agency with the necessaryinformation; (8) Periodically communicate with the Medicaid agency to determine if there have been lapsesin health insurance coverage for Medicaid applicants and recipients; and (9) Request employers and other groups offering health insurance coverage that is beingenforced by the CSE agency to notify the CSE agency of lapses in coverage. In addition, a medical child support order must contain the following information in order to be " qualified ": (1) the name and last known mailing address of the participant and each childcovered by the order, except that the order may substitute the name and mailing address of a stateor local official for the mailing address of any child covered by the order; (2) a reasonabledescription of the type of health coverage to be provided (or the manner in which such coverage isto be determined); and (3) the period to which the order applies. To help obtain health care coverage for children, a 1998 law authorized the creation of the NMSN. The NMSN is a standardized federal form that all state CSE agencies are supposed to usewhen issuing a medical support order to employers. An appropriately completed NMSN isconsidered to be a "Qualified Medical Child Support Order," and as such must be honored by thenoncustodial parent's employer's group health plan.