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Administration for Children and Families US Department of Health and Human Services
The Office of Child Support EnforcementGiving Hope and Support to America's Children

Reasonable Cost and Cash Medical Support
Dilemmas and Ideas to Overcome Them

We welcome you to join our discussion and hope this matrix will allow you to more thoughtfully engage in today's discussion around reasonable cost and cash medical support enforcement. Learning and applying best practices from others is a key indicator of a quality organization. And it works!!

Issues and Questions What has Texas done or is it planning to do? What has Washington done or is it planning to do? What is my state planning to do?
Did I hear anything that I might take back with me to explore with my leadership team?
1. The draft federal regulations allow states to establish a quantifiable reasonable cost standard. How does (or will) your state define reasonable cost? Nine Percent of the gross resources of the NCP (Includes more than just wages). Washington uses a formula tied to the obligor's basic support order amount (25% of the BSO) as determined under the state's child support guidelines.  
2. If health insurance is not available at a reasonable cost, does your state require:
  • Enrollment (if eligible) in Medicaid or other subsidized health care?
  • A cash medical obligation?
  • Financial responsibility for uncovered health costs?
  • Cash medical support is the threshold requirement
  • Custodial parent is required to apply
  • Uncovered health care costs are apportioned 50/50
  • Enrollment is not mandatory
  • Washington is working with the Medicaid agency to develop a workable cash medical legislative proposal
  • Yes
  
3. If your state law provides for responsibility for uncovered health care costs:
  • How are those costs apportioned between the parents?
  • If the children are on Medicaid, does your state pursue "uncovered" costs?
  • 50/50
  • No
  • Proportionate (Although orders may either reflect an obligation based on the same ratio established by the shared income child support guidelines or equal levels of responsibility)
  • Not generally and not through the IV-D system

Issues and Questions What my state is doing now or planning to do? Ideas I've heard from other states here today Things I will take back with me to explore with my leadership team
4. If your state law provides for a cash medical support obligation:
  • How is that amount determined?
  • Does it apply to both parents?
  • Where does the cash medical support go when it is collected and the family receives:
    1. TANF & Medicaid
    2. Medicaid Only
    3. Other subsidized health coverage
    4. No Assistance
(Note: Has your state Medicaid agency indicated it will accept cash medical support collected by the IV-D agency - particularly in "fee for service" cases?)
Do you have any data on amounts collected or cost avoided?
If/when the non-custodial parent provides proof of insurance, what does your state do?
  • Historically, it was a nominal default amount (e.g. $25/month); now it is clarified as 9% of gross resources
  • Typically, the cash medical requirement only applies to the NCP
  1. Medicaid
  2. Medicaid
  3. N/A
  4. Family
FY 06 $41.8 Million in cash medical with $15 Million going to Medicaid & $26.8 Million going to CP.
FY 07 $52.9 Million collected so far ($18.5 to Medicaid & $34.4 to CP).
Obligor may discontinue payment of cash medical support if child is enrolled in appropriate health insurance. 		All to be determined
Current discussions are underway to determine whether it would be feasible to link collections to health opportunity accounts which could be administered by the Health Care Authority. 		 

Issues and Questions What my state is doing now or planning to do? Ideas I've heard from other states here today Things I will take back with me to explore with my leadership team
5. How does your state define "appropriate" health insurance coverage? [Affordability? Accessibility? Comprehensiveness?] N/A Working on an accessibility standard based on proximity to health care that is covered by the insurance.  
7. What other issues do you expect to face in implementing the proposed regulations and/or in looking to the future of enforcing medical support?  
  • More work - same staffing levels
  • Competition for limited resources in state budgets
  • Practical questions about the Return on Investment (ROI) - when the current funding and incentive structure inadequately addresses the medical support workload and does not take into account costs avoided or amounts recovered through coordination of benefits
  • Identity Crisis - who is the obligor and obligee? A new world of setoffs and contests.