For a child, health care is critical. Yet, in the United States today, there are close to over 10 million children without health care coverage. For children who grow up in divorced, separated, or never-married families, the risk of not having health care coverage is great. Of the 21 million children who are eligible for child support enforcement services, approximately 3 million are without health care coverage. These children have substantially less access to health care services, including preventive care that ensures childhood immunizations, vision and hearing screening, and dental care. Health care services are also far more likely to be delayed due to cost. Unmet health care needs reduce a child's ability to grow into a healthy and productive adult.
There is no single reason why children do not have the health care coverage they require. Children, particularly those impacted by the consequences of a family breakup, have not been held harmless from large societal changes: the rising cost of health insurance, the move towards new health insurance models (such as Health Maintenance Organizations) that limit service area and choice of provider, changes in the labor market, the transformation of the American welfare system, and changes in family structure.
Over time, the Federal and State governments have responded to the need for health care coverage for children in two ways. First, they have created publicly-subsidized programs such as Medicaid and, most recently, the State Children's Health Insurance Program (SCHIP). Both programs are need based, primarily serving families with incomes under 200 percent of poverty. Second, the establishment and enforcement of medical child support was added to the responsibilities of the national Child Support Enforcement Program established under Part D, Title IV of the Social Security Act. States are required to include provisions for health care coverage in State child support guidelines and the IV-D program is required to pursue private health care coverage when such coverage is available through a noncustodial parent at a reasonable cost.
Over the past five years a number of legislative changes have strengthened medical child support enforcement and removed some of the impediments to providing children with health care coverage. The Omnibus Budget Reconciliation Act of 1993 (OBRA '93) created the Qualified Medical Child Support Order (QMCSO) and required State laws that prohibit insurers from discriminating in the provision of health insurance when children are born out of wedlock or are outside the insurer's service area. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) required a provision for health care coverage in all child support orders and directed the child support enforcement agency to notify an employer of the noncustodial parent's medical child support obligation.
Despite such reforms, getting and keeping health care coverage for child support-eligible children remains complicated and resource intensive. New strategies and policies are required to make the system easier and more cost effective for parents, employers, health care plan administrators and the government. The goal is both to gain access to better coverage for more of these children and ensure health care coverage for all.
[ Go to Contents ]
Congress recognized the scope of the problem and the eagerness of various sectors to address these issues by creating the Medical Child Support Working Group as part of the Child Support Performance and Incentive Act of 1998 (CSPIA). Jointly established by the Secretary of Health and Human Services and the Secretary of Labor, the Working Group was charged with identifying barriers to effective medical support enforcement and developing recommendations that address the following six areas:
[ Go to Contents ]
The Working Group is a powerful example of very different worlds coming together, learning each other's languages, developing a greater understanding of legitimate competing concerns, and reaching consensus on real solutions to complex issues.
The Working Group includes thirty members with representatives from the U.S. Department of Labor (DOL), the U.S. Department of Health and Human Services (HHS), State IV-D Child Support Directors and State Medical Child Support Programs, State Medicaid Directors and SCHIP programs, employers, including small business, trade or industry representatives and human resource and payroll professionals, plan administrators and sponsors of group health plans, child advocacy organizations, and organizations representing State child support programs.
The Working Group's greatest challenge was balancing the concerns and interests of the various stakeholders — Federal representatives, State IV-D/Child Support Enforcement, State Medicaid and SCHIP, employers, insurers, plan administrators, child advocates, private attorneys, and representatives of the courts.
The Working Group met eight times since its first meeting in March 1999 and came to consensus on 76 recommendations. Based on testimony and research, the Working Group formulated a package of recommendations with children in the center, based on the idea that the system and structure should work toward what is best for the child. The Working Group was guided by a set of principles, including:
It is in the best interest of both children and the nation that the maximum number of children have access to health care coverage. Lack of such coverage affects children's current and future health and their ability to become productive citizens.
Parents share primary responsibility for meeting their children's needs. When one or both parents can provide comprehensive, accessible, and affordable health care coverage that coverage should be provided to the child. To the maximum extent possible, public dollars through enrollment in Medicaid/SCHIP should not replace private insurance but rather should serve as the payer of last resort where private health care coverage is unaffordable, unavailable, or not comprehensive enough. Public coverage is not intended to relieve able parents of their responsibility to provide health care for their children.
Coverage available to both parents should be considered in setting a medical support obligation. Twenty-seven States recognize that both parents may have access to private insurance and direct the decision maker to consider both parents as a potential source. However, nearly half of the States' child support guidelines do not direct the decision maker to consider coverage available to the custodial parent and, as a result, children may be missing out on potential coverage. These recommendations change the child support enforcement's medical support focus, which is now almost exclusively on the noncustodial parent.
In deciding whether to pursue coverage, the cost of coverage is an important consideration. However, the current Federal definition of "reasonable" health insurance — that it is available through an employer — is not necessarily reasonable. The Working Group explored alternative State and Federal definitions, including the SCHIP guidance that the cost of SCHIP premiums should not exceed five percent of a family's gross income, and the applicable Consumer Credit Protection Act (CCPA) limits. The recommendations address concerns that the cost of private health care coverage could significantly lower the amount of cash support available to meet the child's basic needs and the child is eligible for some other form of health care coverage.
When private health care coverage is available to a child, the child support enforcement agency should consider the geographic accessibility of covered services before it decides to pursue the coverage. Given, in particular, the large number of interstate child support cases, the Working Group concluded that children should not be enrolled in any limited provider plan whose services/providers are not accessible to them, unless the plan can provide financial reimbursement for alternate service providers. In its recommendations, the Working Group considers coverage by Health Maintenance Organizations (HMOs), and other plans which limit providers, accessible if the provider may be reached within 30 minutes or 30 miles, but allows States to adopt an alternative standard.
The child support enforcement program should work in close conjunction with Medicaid and the SCHIP to ensure that children who have access to private coverage obtain such coverage and those who need publicly subsidized coverage are covered by Medicaid or SCHIP.
[ Go to Contents ]
The Working Group spent considerable time deliberating, listening to testimony, studying research, and meeting in subcommittees.
The Working Group's deliberations led to 76 recommendations. While many are practical and technical, others are visionary — a dramatic shift to a new paradigm — necessitating fundamental changes to State and Federal government's management and operations of medical child support enforcement. Some of the recommendations are Federal mandates, others are "best practices" to be shared with States, employers, and others. The implementing strategy for each recommendation falls within one or more of the following categories:
Considering the complex interplay of trends in health care delivery, labor market, and family structure, the Working Group has formulated a comprehensive strategy that overhauls the current medical support system for the country's 21 million child support-eligible children. Enactment or adoption of these recommendations will increase the number of children with private health care coverage and increase access to publicly-funded health care coverage for children who cannot obtain private coverage. Throughout, the Working Group recommends a broader, more proactive role and responsibility for IV-D agencies in ensuring that children have health care coverage. As a necessary companion to these mandates, the Working Group recommends immediate enhanced funding to IV-D programs for medical support enforcement. Although the enhanced funding is time-limited, the recommendations also address research and future funding.
The solutions developed by the Working Group are most easily considered in two broad categories: recommendations that ensure seamless health care coverage for all children and recommendations that streamline medical support enforcement. Below is a sampling of the Working Group's 76 recommendations:
[ Go to Contents ]
This Report will assist policy makers in developing technical and substantive changes to statutes and regulations. It will provide best practice information to States and employers.
The Report is organized into nine chapters. The first two chapters provide an overview and background. Chapter 1 addresses the scope of the problem and Chapter 2 provides an overview of the current system from the perspective of the Child Support Enforcement Program (IV-D), as well as from the perspective of the employer and plan community. This Chapter lays out not only the requirements and suppositions built into current law but also offers a new paradigm for ensuring health care coverage for all child support-eligible children.
A critical step in child support is establishing the child support order. Chapter 3 offers a detailed analysis and comprehensive reform of both how health care is included in a child support obligation and how that order is drafted. Chapter 4 discusses the enforcement tool for IV-D medical support orders, the National Medical Support Notice. Chapter 5 is a broader discussion of enforcement of the health care provisions in a child support order. Chapter 6 is a macro discussion of system coordination. Funding of child support activities directly related to medical support can be found in Chapter 7. Chapter 8 identifies additional strategies and research required to ensure ongoing improvements in assuring health care coverage for children in single parent families. Finally, Chapter 9 provides a brief Postscript/Conclusion to the Report.
[ Go to Contents ]
The Working Group's recommendations are designed to create an easier, more cost effective, and comprehensive medical child support enforcement system. Suggested strategies and laws will move our society a long way down the road to ensuring that children are protected from the health care consequences of family dissolution. Finally, although it is the Working Group's goal that this Report frame the focus and future direction of medical child support enforcement within the IV-D program, it is our hope that the consensus built here will also provide a model for sorting through the complex interplay of competing interests and move as a society to ensure health and well-being to all America's children.
[ Go to Contents ]
Top of Page
Contents
Contents of Report
Home Pages:
HHS Fatherhood Initiative
Assistant Secretary for Planning and Evaluation
(ASPE)
U.S. Department of Health and Human Services
(HHS)
Last updated: 11/17/00