1. Child Support Directors Association of California in partnership with California Department of Child Support Services Medical Support Regulations: Changing Times October 5-7, 2010 | Orange County, California

2. Presenters and Moderator Presenters: Lori Cruz, Deputy Director Los Angeles County DCSS Terrie Hardy-Porter, Director Sacramento County DCSS Lesley Hull, Branch Chief Program Policy Branch, California DCSS Moderator: Natalie Metzger, Policy/Communications Analyst California Child Support Director’s Association

3. Federal Medical Support Background ■In 1998, there was recognition at the federal level, that the provision of health care for children was a critical issue ■Out of the need to address the issue came the Child Support Performance and Incentive Act of 1998, which established the National Medical Child Support Working Group ■A final report entitled 21 Million Children’s Health: Our Shared Responsibility was transmitted to Congress in August 2000

4. Federal Medical Support Background ■This report served as the basis for the development of the new federal Medical Support regulations ■After consultation with a wide range of stakeholders, review of the 21 Million Children report and a study conducted by Health and Human Services the federal medical support regulations originated ■The final regulations became effective July 21, 2008

5. Federal Medical Support Background ■States have been given until 2014 to come into compliance with the new regulations ■Medical support is currently scheduled to be linked to incentives in 2014

6. Federal Medical Support Regulations ■Medical Support Regulations were based on the premise that States already have active medical support programs in place ■The changes: require that all support orders in the IV-D program address medical support; redefine reasonable-cost health insurance; require health insurance to be accessible, as defined by the State; and make conforming changes to the Federal interstate, substantial-compliance audit, and State self-assessment requirements.

7. 45 CFR 302.56(c)(3) ■Sec. 302.56 Guidelines for setting child support awards. * * * * * (c) * * * (3) Address how the parents will provide for the child(ren)'s health care needs through health insurance coverage and/or through cash medical support in accordance with Sec. 303.31 of this chapter. * * * * *

8. Federal Medical Support Regulations ■States must address how the parents will provide for the child(ren)’s health care needs through health insurance and/or case medical support ■Federal regulations definition of reasonable costs is not exceeding 5% of the parents gross income; States were allowed to revise this definition ■Application of reasonable cost was defined as the cost of adding the child(ren) to existing coverage or the difference between self-only and family coverage

9. Federal Medical Support Regulations ■Mandates inclusion of a provision in the order for cash medical to cover time periods when health insurance is not reasonable and accessible ■Mandates States to establish a definition for accessible ■Cash medical can include when the obligated parent pays a premium or co-pay to public health insurance ■Does not mandate but allows for States to choose to enforce medical support against the custodial party

10. California’s Response ■Formation of a multi-disciplinary workgroup to: ✷ conduct analysis of the new federal regulations ✷ Identify gaps ✷ Provide recommendations to address gaps ✷ and address any gaps that were found ■A bill sponsored by Senator Wright (SB580) would be the vehicle used to address legislative gaps; allowing California to move into compliance

11. Workgroup Guiding Principles ■Guiding Principles ✷ When CA State law adequately meets the Federal Regulations, no changes to current state law should be recommended ✷ No recommendation should adversely impact current support or arrears performance ✷ Recommendations consider the current resource level and workload in the courts and within the local service delivery agency

12. Key Workgroup Focus Areas ■Review current state law, regulation, and policy regarding: ✷ A definition for cash medical ✷ A definition for reasonable cost ✷ A definition for accessibility ■Analyze the possibility of incorporating cash medical into the guideline formula ■Identify automation issues and/or other dependent factors for implementing new medical support provisions

13. Medical Support Analysis ■Review of the new regulations, current California State Law, current California Child Support Regulations, and policy identified 3 primary gaps now federally mandated, but not addressed: ✷ Income-numerical value for defining what is considered reasonable ✷ A definition as to what is considered accessible health insurance for the child(ren) ✷ A cash medical support provision in the order to address gaps when health insurance is unreasonable and not accessible

14. Medical Support Analysis ■Initial gap analysis findings included: ✷ FC 3751(a)(2) did not provide an income- numerical value to the definition of reasonable or define or consider accessibility of the health insurance to the child ✷ FC 4062(a)(2) provides the ability to include in the order a provision for reasonable uninsured health care costs, but did not mandate this provision in orders

15. Workgroup Primary Recommendations ■Definition of reasonable costs: ✷ 10% of obligated parents gross income ■Definition of accessible: ✷ Within 50 miles of the child ■Definition of cash medical: ✷ Use of unreimbursed medical costs clause currently included in orders ■Do not mandate enforcement of health insurance against the custodial party

16. SB 580 ■Amended sections include: ✷ FC § 3751(a)(2) – provides the definition of reasonable cost ✷ FC § 4061 – eliminates non- mandatory language ✷ FC § 4063(g)(1) – provides the definition for accessible ✷ FC § 17422(b)(3) - provides the definition of reasonable cost

17. SB 580 ■Provides a income-numerical value for defining reasonable costs ■Defines health insurance as unreasonable when using the low-income adjustment ■Provides a numerical value for what is considered accessible health insurance for the child ■Eliminated “if ordered to be paid” language in FC § 4061 ■Provides discretion to the courts to protect against an unjust or inappropriate elimination of health insurance

18. FC § 3751(a)(2) ■Reasonable Cost for Health Insurance defined: ✷ Health insurance coverage shall be rebuttably presumed to be reasonable in cost if the cost to the responsible parent providing medical support does not exceed 5 percent of his or her gross income. ✷ Example: Obligated Parent gross income = $30,000 ($2,500 monthly) Health insurance costs could not exceed $125 a month

19. FC § 3751(a)(2) ■Application of the definition: ✷ In applying the 5 percent for the cost of health insurance, the cost is the difference between self-only and family coverage. ✷ Example: Obligate Parent income $30,000 ($2,500 mthly) Cost to insure self: $300 Cost to add child addt’l: $75 Health insurance considered reasonable as it is less than 5% of gross (or $125 a month)

20. FC § 3751(a)(2) ■If the obligor is entitled to a low-income adjustment as provided in paragraph (7) of subdivision (b) of Section 4055, medical support shall be deemed not reasonable, unless the court determines that not requiring medical support would be unjust and inappropriate in the particular case. ✷ Note:The intent of the discretion was to protect against obligated parents currently providing health insurance from automatically getting a modification to no longer be required to provide health insurance base upon the new law

21. FC § 4061 ■The amounts in Section 4062 shall be considered additional support for the children and shall be computed in accordance with the following: ✷ (a) If there needs to be an apportionment of expenses pursuant to Section 4062, the expenses shall be divided one-half to each parent, unless either parent requests a different apportionment pursuant to subdivision (b) and presents documentation which demonstrates that a different apportionment would be more appropriate.

22. FC § 4063(g)(1) ■Health insurance shall be rebuttably presumed to be accessible if services to be provided are within 50 miles of the residence of the child subject to the support order. If the court determines that health insurance is not accessible, the court shall state the reason on the record.

23. FC § 17422(b)(3) ■Health insurance coverage shall be considered reasonable in cost if the cost to the responsible parent providing medical support does not exceed 5 percent of his or her gross income. In applying the 5 percent for the cost of health insurance, the cost is the difference between self-only and family coverage. If the obligor is entitled to a low-income adjustment as provided in paragraph (7) of subdivision (b) of Section 4055, health insurance shall not be enforced, unless the court determines that not requiring medical support would be unjust and inappropriate in the particular case.

24. Issues Moving Forward ■Operationalizing the definition of reasonable cost for health insurance ■Availability of information regarding costs of health insurance ■Ensuring unreimbursed medical expense language is included in all orders

25. Issues Moving Forward ■Form and potential language changes ■Current CSE functionality and any necessary changes ■Data collection for performance reporting concerns ■Revision of any California regulations and/or policy letters addressing medical support

26. Proposed Policy Direction ■Presumption that barring information to the contrary health insurance is available at reasonable cost ■Burden placed on the obligated parent to demonstrate actual cost of health insurance is unreasonable to provide ■If health insurance is found to be unreasonable and/or unaccessible cash medical clause in place to allow for the recovery of medical costs

27. Additional Information ■Federal Level ✷ Passage of Patient Protection and Affordable Care Act (Health Care Reform) ✷ Action Transmittal sent to all State Agencies (AT- 10-02) OCSE currently analyzing medical child support requirements Holding States harmless as they assess how IV-D medical child support fits into health care reform To come will be policy guidance and rulemaking which may include interim regulations

28. Additional Information ■State Level: ✷ Moving forward with the implementation of SB 580 ✷ Will assess the impact of changes at the federal level as they are provided

29. Questions

30. Presenter Contact Information Lesley Hull, Branch Chief Program Policy Branch, California DCSS Lesley.Hull@dcss.ca.gov Terrie Hardy-Porter, Director Sacramento County DCSS Portert@saccounty.net Lori Cruz, Deputy Director Los Angeles County, DCSS Lori_Cruz@cssd.lacounty.gov

31. Resources ■Federal Medical Support Final Rule ✷ http://www.acf.hhs.gov/programs/cse/pol/AT/2008/at- 08-08a.htm http://www.acf.hhs.gov/programs/cse/pol/AT/2008/at- 08-08a.htm ■SB 580 ✷ http://www.leginfo.ca.gov/pub/09-10/bill/sen/sb_0551- 0600/sb_580_bill_20100715_chaptered.pdf http://www.leginfo.ca.gov/pub/09-10/bill/sen/sb_0551- 0600/sb_580_bill_20100715_chaptered.pdf ■AT-10-02 ✷ http://www.acf.hhs.gov/programs/cse/pol/2010-at.html http://www.acf.hhs.gov/programs/cse/pol/2010-at.html ■Child Support Regulations ✷ http://www.childsup.ca.gov/Resources/ChildSupportRegulat ions/tabid/144/Default.aspx http://www.childsup.ca.gov/Resources/ChildSupportRegulat ions/tabid/144/Default.aspx

32. Additional Resources ■Child Support Policy ✷ http://www.childsup.ca.gov/ChildSupportProfessionals /Policies/tabid/92/Default.aspx http://www.childsup.ca.gov/ChildSupportProfessionals /Policies/tabid/92/Default.aspx ■California Central ✷ https://central.dcss.ca.gov/PPR/default.aspx https://central.dcss.ca.gov/PPR/default.aspx ■California Child Support Directors Association ✷ http://www.csdaca.org/default.aspx http://www.csdaca.org/default.aspx ■Patient Protection and Affordable Care Act ✷ http://thomas.loc.gov/cgi- bin/bdquery/z?d111:H.R.3590 http://thomas.loc.gov/cgi- bin/bdquery/z?d111:H.R.3590