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In 1999, the Connecticut legislature passes a statute that directs the court or Family Support Magistrate to include in each support order in a IV-D case a provision for the child to be named as a beneficiary by either parent of any medical and dental insurance available to the parent on a group basis through an employer or union. The statute goes on to state that:
… if such insurance coverage is unavailable to the parent at reasonable cost, the provision for health care coverage may include an order for either parent to apply for and maintain coverage on behalf of the child under the HUSKY Plan, Part B.(33) The noncustodial parent shall be ordered to apply for the HUSKY Plan, Part B only if such parent is found to have sufficient ability to pay the appropriate premium. In any IV-D support case in which the noncustodial parent is found to have insufficient ability to provide medical insurance coverage, and the custodial party is the HUSKY Plan, Part A or Part B applicant, the provision for health care coverage may include an order for the noncustodial parent to pay such amount as is specified by the court or Family Support Magistrate to the state or the custodial party, to offset the cost of any insurance payable under the HUSKY Plan, Part A or Part B.(34)
Organization of Agencies
The Department of Social Services is the umbrella agency in Connecticut responsible for administering 90 legislatively-authorized human services programs, including the child support program, Medicaid and SCHIP. There is a regional administrator responsible for each of five services regions, and each region oversees at least several local offices among the 15 local offices across the state that are delivering child support and medical services.
The Deputy Commissioner for Programs in DSS plans and develops child support regulations, policies and procedures, and coordinates and monitors the implementation of services. Coordination is undertaken with the Family Support Magistrates who hear IV-D child support cases, the Assistant Attorneys General who present child support cases before the court, and staff in the Support Enforcement Services (SES)/Court Operations Division(35) of the Judicial Branch of state government. Medicaid and SCHIP are split between the Medical Administration and Policy Division and the Medical Care Operations Division of DSS. The SCHIP program is a combination program, meaning that it is both a Medicaid expansion and a stand-alone program.
Goals, Origins and Implementation
Goals. The goals of Connecticut's legislation and associated practices were to promote more coordination between the HUSKY and child support programs. Such coordination was and is aimed at instituting more ways that noncustodial parents can contribute to the health care coverage costs of their children, and save public costs to HUSKY. The OIG report had estimated that the state could save $11.4 million in annual combined state and federal Medicaid costs by following the OIG recommendations.
It is also apparent that coordination is a significant goal for each agency involved in the operation of child support and public health insurance programs. The Department of Social Services strives to be a caring and responsive organization that effectively and efficiently delivers the highest quality services to help their customers improve the quality of their lives and achieve and maintain maximum self-sufficiency. To that end, DSS is under a statutory requirement that the Commissioner establish a statewide advisory council. This council's mission involves consulting with and advising the Commissioner on the development and delivery of human services for Connecticut's families and individuals who need assistance [in maintaining or achieving their full potential for self-direction, self-reliance and independent living]. Among the responsibilities of the Council are to identify service delivery gaps and changing service needs, and to increase the capacity of the department to collaborate and plan with other human service agencies to maximize the utilization of existing resources.
The goal of the Director of the state's Bureau of Child Support Enforcement is for children to move smoothly from Medicaid to SCHIP to private insurance (and back again if need be) as family circumstances change. To that end, coordination with the Medical Administration and Policy Division is written into her work plan and into the work plan of the Central Office Program Manager.
Officials of the HUSKY program observed that their principal mission goal has been to enroll the maximum number of eligible children in HUSKY Part A or B and, to that end, to conduct an aggressive outreach effort. However, with recent budget shortfalls in the state, HUSKY no longer spends its own funds on outreach. Instead, the program in 2002 relies on a separate Children's Health Council, the state's lead agency for the Covering Kids and Families program funded by The Robert Wood Johnson Foundation, facilitates state and local efforts to design and conduct outreach programs that identify and enroll eligible children into Medicaid and other coverage programs, and aims to simplify enrollment processes and to coordinate existing coverage programs for low-income children.
The Director of Medical Care Administration speaks to the need for collaboration, regularly, in his written communications; and other officials who work with HUSKY point to the coordination they promote between the enrollment broker and local offices.
Origins. Connecticut's 1999 statute was in part the result of a report from a study by the Office of the Inspector General (OIG) in the U.S. Department of Health and Human Services. The OIG study reviewed a computer file extract of Connecticut IV-D children enrolled in Medicaid from April 1, 1996 through March 31, 1997, whose noncustodial parents had court orders to provide medical support. The objective of the review was "…to determine whether children under the Child Support Enforcement Program are receiving Medicaid benefits because private health insurance is unavailable or unaffordable to noncustodial parents."(36) The report found that more than half of noncustodial parents from the sample cases could not meet their medical support obligations because their employers did not offer health insurance or the insurance was not available at a reasonable cost. However, OIG also found that the same noncustodial parents could afford to pay all or part of Connecticut Medicaid premiums. The study concluded that the state of Connecticut could increase the number of noncustodial parents providing medical support for their children and save an estimated $11.4 million (Federal and State combined) in annual Medicaid costs by implementing alternative arrangements. OIG recommended two alternatives. The first was for Connecticut to implement policies and procedures to require noncustodial parents to pay all or part of the Medicaid premiums for dependent children. The second was for the state to establish a statewide health insurance plan that provided reasonably priced comprehensive health coverage for children and required noncustodial parents to contribute to premiums.
Implementation. The state of Connecticut agreed that the OIG's findings had merit and responded by examining both recommendations. The Commissioner of the Department of Social Services agreed to consider OIG's first recommendation of requiring noncustodial parents to pay all or part of Medicaid premiums as a legislative change and budget option for the 1999 legislative session. The state's establishment of the SCHIP program under Title XXI of the Social Security Act addressed OIG's second recommendation to establish a statewide health insurance plan for children. Connecticut implemented affordable health coverage under the HUSKY Plan in June 1998 for uninsured children of low-income families with incomes above the eligibility cutoff for Medicaid. Accompanying language from the statute establishing SCHIP(37) defined an applicant to include noncustodial parents who are under order to apply for HUSKY Part B coverage on behalf of children when access to reasonably priced health insurance coverage is unavailable.
During the 1999 legislative session, the Commission for Child Support Guidelines expanded and clarified child support provisions by adding a new subsection.(38) The subsection requires every child support award to include a provision for either parent to contribute to the health care coverage of the child. Either parent may name the child as beneficiary of health insurance carried at a reasonable cost. However, if insurance is not available at a reasonable cost, the order may require application for HUSKY, and the noncustodial parent's monetary contribution toward premium costs is established as part of the support order.(39)
Subsequent HUSKY statutory provisions amended several sections of child support legislation.(40) Some allow a Family Support Magistrate to order either parent to apply for and maintain HUSKY. If the custodial family is in HUSKY A or B, the Magistrate may order the noncustodial parent to pay a set amount to the state or the custodial parent to offset premium costs. However, such payment may not be ordered if it would reduce the amount of current child support required under the guidelines. The last provision is seen by nearly all respondents to our interviews as setting up an inequity between those noncustodial parents ordered to provide private coverage, and those noncustodial parents ordered to reimburse the state or custodial parents to offset the cost of public insurance premiums.
Because each agency needed a better understanding of the legislation and HUSKY, training was provided to child support staff as well as to the Family Support Magistrates. Training consisted of two parts. The first piece was about the HUSKY program, its functions, benefits, and the role of the enrollment broker that is contracted to screen applicants for SCHIP and Medicaid eligibility and to enroll families. The second piece was a discussion about the new legislation and how it was going to be implemented. Magistrates received only the HUSKY training, while all child support workers and Support Enforcement Services (SES)(41) staff received both parts of the training. Staff from the Attorney General's office went to either training. Children's Health Project (CHP) staff, one of several HUSKY outreach contractors, ran the HUSKY training. Several child support investigations supervisors from regional office were identified to be trainers for all child support staff on how the statute was to be implemented. SES adopted the same training manual used by those supervisors and adapted it to train SES staff. Training sessions were held in all five regional and 15 local offices across the state, except for staff from particularly small offices who were brought together for combined trainings.
Some of the fifteen local child support offices, such as the Danbury office, implemented with greater ease than others because of smaller IV-D caseloads and lighter court dockets, as compared with Hartford and New Haven, and more open dialogue with Magistrates. When legislation for medical orders was initiated, the child support program did not receive any additional funding or staff in order to address it. However, the supervisor moved caseloads around to try to spread out Medicaid-only cases, and instead of creating specialized positions the lead investigator has become very knowledgeable about medical support.
Current Child Support Operations
The Connecticut IV-D program serves both clients who are mandated to cooperate with child support as a prerequisite for TANF or Medicaid receipt and those who apply for child support enforcement services. In cash assistance and Medicaid public assistance cases the information about the noncustodial parent is obtained by the cash assistance/Medicaid eligibility worker and referred to the child support program. Child support enforcement staff locate the noncustodial parent, establish paternity, and establish orders. Orders may be established through noncustodial parent signature of an Agreement to Support (ATS), which specifies the support amount calculated based on the noncustodial parents finances and is submitted to the court for approval. The child support office prefers handling more cases this way, rather than by legal petition, because paternity and support orders are established sooner, and it is better for arrearage management. However, very few orders are established this way. As an example, for State Fiscal year 2002, statewide, there were 8847 orders established through legal action, and 167 by an Agreement to Support. All available information is entered into the Connecticut Child Support Enforcement System (CCSES).
At this point in TANF and Medicaid cases, the investigator may know the noncustodial parent's ability to provide health insurance from investigating the noncustodial parent's employment and income. For a non-public assistance case, the custodial parent can be interviewed during the application interview, and the insurance status of the children and any possible coverage by either parent can be examined. Otherwise the information may not be known until the noncustodial parent fills out a financial affidavit and both parents are asked about medical coverage, which both take place in court. Child support staff are encouraged to determine coverage before going to court so that they can request an appropriate order from the Magistrate. However, they often are unable to gather sufficient information, which leads to many continuances with some of the Magistrates. Continuances are also necessary when requesting that either parent apply for HUSKY (especially for cases in which the noncustodial parent is self-employed or employed and health insurance is either not available or available at an unreasonable cost), as the parties await eligibility determination.
The IV-D case is brought before the court's Family Support Magistrate(42) by the Assistant Attorneys General. They call on the DSS child support investigator who has worked up the case to testify. Each Magistrate handles the medical support portion of the order differently. The Magistrate must first determine the nature of each parent's health plan or lack thereof. If the child is uninsured, the Magistrate will make a standard order for both parties to provide medical and dental through an employer-provided or union-provided insurance or "another group plan", and the case will come back to court after eligibility is determined for health coverage. A Magistrate may make a general reference to applying for HUSKY by ordering application to "another group health plan," or may specifically order HUSKY. If the custodial parent has already established insurance for the child or returns to court having been found eligible for HUSKY A or B, the noncustodial parent may be ordered to contribute towards the cost of the premiums.
In interviews with three Magistrates in Danbury, we learned that each one defines reasonable cost slightly differently but more specifically than the federal definition. One magistrate said they cap it at 10 percent of gross income and that with low-income obligors this usually works out to $30 per week. Another said they cap it at nine percent of gross income, but agreed it usually works out to $30 per week for low-income obligors. Another Magistrate observed that DSS has been reluctant to impose a single definition of reasonable cost on the courts, and they do not want them to do so.
After the order is established, the child support investigator refers the case to Support Enforcement Services and if the child was uninsured at the time of the order, the parents begin the insurance application process. If the noncustodial parent adds the child to his employer or union policy, he notifies the child support investigator that he has complied. If the custodial parent already has insurance for the child, or returns to court having been found eligible for HUSKY A or B, the noncustodial parent can be ordered to contribute towards the premium costs. The SES support enforcement officer monitors the case to ensure that the noncustodial parent maintains insurance coverage for the child or continues to contribute towards the cost of the premiums, and officer may use any necessary tools to that end (i.e. income withholding, license suspension, etc.).
If the noncustodial parent changes jobs, SES will receive automated notice of the change from the CCSES New Hire database, review the case, and issue a new order for insurance to the new employer. If the noncustodial parent has already established insurance for himself at his new job but not for the child, SES can order the employer to enroll the child on the noncustodial parent's plan. If the noncustodial parent is not enrolled on the new insurance plan, SES can bring the parent back to court for failure to obtain or maintain health insurance. The noncustodial parent will be ordered to enroll himself and the child (if reasonably priced insurance is available from the employer) and bring proof back to the court, or be threatened with jail time. If reasonably priced insurance is not available from the new employer, the noncustodial parent can be ordered to apply for HUSKY. Even if the noncustodial parent's application is rejected because the custodial parent must ultimately apply and provide her income information, the noncustodial parent can present the rejection letter as proof of compliance with his court order.
If the custodial parent adds the child to her employer or union policy or the child is enrolled on HUSKY A or HUSKY B, the case returns to court to arrange the noncustodial parent's contribution towards premiums. If the noncustodial parent fails to contribute toward the premium at any point, SES will file for contempt and bring the noncustodial parent back to court. No contribution from the noncustodial parent may be ordered, if the child is enrolled in a HUSKY plan and a premium contribution would lower the dollar value of the cash child support order.
HUSKY officials noted the importance of coordination with child support officials to working out kinks when the noncustodial parent applies for HUSKY. Unless the noncustodial parent provided all the necessary information about the custodial parent, HUSKY enrollment broker staff rejected the applications on the grounds that they could only take application from custodial parents. HUSKY officials reeducated enrollment broker staff on how to facilitate the enrollment process for IV-D children, such that upon receipt of a HUSKY application from noncustodial parents, staff would send a blank HUSKY application to the noncustodial parent instructing him to send it on to the custodial parent. Alternatively, staff could send a letter to the custodial parent, directly, requesting that she fill out an enclosed HUSKY application to accompany the one submitted by her child's noncustodial parent.
More recently, there has been additional coordination between HUSKY and BCSE staff over revisions to the HUSKY application. BCSE staff had become frustrated, over the referral of parents applying for public health care coverage for their children to child support enforcement for services. Experts in Connecticut and other states submit that many such custodial parents referred to CSE eschew child support services and do not cooperate in a manner sufficient to "work the case." Thus, the child support caseload becomes populated with unworkable cases. To correct this problem, BCSE officials asked HUSKY officials to add a screening question to the HUSKY application. It not only corrects that problem, but also invites those who might not have thought about receiving full child support services, to consider doing so and indicate their decision. Though still in draft form, and not yet approved by all parties for distribution, the new application contains a section called, Parents Who Do Not Live in the Household, which explains under what circumstances a custodial parent must cooperate with child support (when they want HUSKY coverage for themselves) and how they may be exempted from this requirement. It also asks whether the custodial parent would like to obtain services even if they do not want HUSKY for themselves. If the custodial parent agrees to pursue support, they fill out an information chart that asks for the name of the noncustodial parent, name of the child, parent's address, and name/address/phone number of the parent's employer.
Finally, coordination between BCSE and SES seems to be thorough. The flow of cases from BCSE, where they are made "enforceable orders" to SES, where they are "enforced" is smooth, and staff we spoke with in both groups seem to be on the same page both about how the process flows now, and how it will flow with the introduction of the National Medical Support Notice on October 1, 2002.(43)
Current Medical Assistance Operations
If the Magistrate determines that insurance is not available at a reasonable cost, the Magistrate may order the noncustodial parent to apply for HUSKY. To apply for HUSKY, the noncustodial parent calls the 1-800 number of the enrollment broker and a customer service representative takes down his or her pertinent information. The noncustodial parent may proceed with the application over the phone or choose to receive a mail-in application. If the noncustodial parent proceeds by phone, the information is entered onto an application and the pre-printed form is sent to the noncustodial parent for verification and a signature. The application is mailed back and given to an eligibility specialist for processing. If the court order is not attached to the application or any other information is required, the enrollment broker's customer service representative will request it.
The file receives a noncustodial parent flag in the enrollment broker's computer system, and a blank application is sent to the noncustodial parent to send to the custodial parent. At the parents' request or if there is a restraining order in place, the broker's representative may get the custodial parent's address and information from the child support caseworker, in order to mail the application directly to the custodial parent for completion. Confidentiality of the custodial parent's information is maintained at all times by broker staff, and staff receive regular retraining on the confidential nature of child support information.
Once the custodial parent's application is received, eligibility is based upon the custodial parent's self-declared income and other expense verifications. If the custodial parent does not send back the proper information, the noncustodial parent will receive a denial letter. Or if the child is already enrolled in HUSKY A, the HUSKY B application will be closed and a letter sent to the noncustodial parent. Each of these letters sent to the noncustodial parent may be used as proof that he or she has complied with the Magistrate's order.
If the appropriate information is received from the custodial parent and the case is determined to be eligible for HUSKY A, it is sent to the Presumptive Eligibility Unit in the DSS Central Office for "granting" as a HUSKY A case. The data will be entered into the Medicaid automated system, the system issues the Medicaid/HUSKY A card, and the case file is transferred back to the appropriate local office for ongoing monitoring and redetermination. If the case is eligible for HUSKY B, the enrollment broker handles the case and "grants" HUSKY B.(44) The specialist processes the application and faxes the information to the appropriate managed care organization with a notice that it is a medical support case and that the bills are to be sent to the noncustodial parent. The managed care plan issues its own card to the custodial parent, and the family does not receive a CONNECT card. A determination letter to the custodial parent is automatically generated by the ACS system, and the specialist sends a designated manual letter to the noncustodial parent to inform him of what program the child has been enrolled in, and how much the premium is. He or she is instructed to contact his child support worker with any payment questions. If the noncustodial parent stops paying the premium, the broker's automated system sends a locked-out notice to the custodial parent, indicating that without payment the child's coverage is frozen. This can generate a successful plea from the custodial to noncustodial parent to resume payments, or a call of complaint to the child support worker, who notifies SES to step in and enforce.
Local Variation in the Courts. In Hartford, we had the opportunity to discuss the legislation with three Family Support Magistrates in the Hartford court, including the Chief Magistrate. They pointed to the variation in their courtroom practices. One Magistrate said he issues "a standard order for medical and dental insurance where available from an employer or union or other group plan at reasonable cost." He does not define other group plan, but means for it to imply HUSKY. When asked how the noncustodial parent understands this to be a directive to apply for HUSKY, this Magistrate said that if the noncustodial parent states that his employer does not offer health insurance, or states that it is available at a cost the Magistrate deems too high for the guideline, the Magistrate will suggest looking into HUSKY. He also stated that he often does not have to define it, because the custodial parent usually knows about HUSKY. Finally, he noted that if the case is brought back before him by SES for contempt, due to the noncustodial parent's failure to obtain any health insurance coverage, that is a second chance for the Magistrate to probe and learn that employer-sponsored coverage is unavailable or too costly, and to suggest that HUSKY will fulfill the order for "or other group plan."
This same Magistrate also recognized how difficult it is to ascertain which parent has a better policy, given that only a few minutes may be spent on each case. (45) He said that some policies have very poor coverage for children, usually without dental, and he often has to issue a continuance until the child support investigator can obtain comparative information on custodial parent or noncustodial parent policies as compared to HUSKY.
A second Magistrate stated that, contrary to the practice of the first Magistrate, he far more frequently orders the noncustodial parent to reimburse the custodial parent (or the state) for HUSKY premiums, once the custodial parent applies for HUSKY and is found eligible. But he noted that this involves some complicated math, because in gauging his order against the guidelines, he must combine the cost of premium reimbursement with the cost of unreimbursed medical expenses. Unlike the first Magistrate, this second Magistrate rarely issues continuances, but rules with the information on health insurance presented at the first hearing.
Both of these Magistrates and the Chief Magistrate were critical of the language in statute that established SCHIP that sets up an inequity between the way the guidelines handle noncustodial parent employer-sponsored health insurance coverage and the way the Public Act directs Magistrates to handle noncustodial parent reimbursement of HUSKY premiums. The guidelines take net income, establish a basic child support obligation, and allow for a deduction from the basic obligation for child's health insurance premium if the noncustodial parent is a low-income obligor. The statute permits the Magistrate to order the noncustodial parent to reimburse the state or the custodial parent for HUSKY premiums, but "In no event may such order include payment to offset the cost of any such premium if such payment would reduce the amount of current support required under the child support guidelines."
Funding Sources and Amounts
No new funding was authorized or appropriated for these practices. The activities were absorbed into regular IV-D administrative costs, the regular judiciary/court expenses, and into the administrative costs in the judicial branch's SES. Thus, medical support ordering and enforcement activities are funded with the 66 percent FFP and 34 percent state funds.
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The principal initiative studied in Minnesota is a statutory requirement and practice wherein the state pays $50 to each county for each child in a public assistance case (receiving cash assistance or medical assistance) in which a private health insurance order is successfully enforced. This bonus payment is made for each child in a child support case and each time in the course of a year that a private health insurance order is enforced. Thus, if a noncustodial parent with three children on public assistance changes employers three times in a year, and each employer is found to have reasonably priced dependent health insurance available to the noncustodial parent in which the medical team assures enrollment, the county will earn $450 in medical health insurance bonus money that year for enforcing that single noncustodial parent's medical support order.
Organization of Agencies
Minnesota's Department of Human Services supervises both the child support and public health care programs. Child support operations are supervised by DHS' Economic and Community Support Strategies division, while Medicaid and MinnesotaCare(46) as well as the SCHIP program are supervised by DHS' Health Care Administration.
Unlike most other states, however, Minnesota counties have a major role in administration, partly because they contribute financially to human services administration and benefits. The result is that child support enforcement and medical assistance programs are state-supervised but county-administered. Some describe the county social services agencies as virtually autonomous entities from their state agency, though the state agency provides oversight and intervenes when there are problems. Thus, much of the implementation and operation of medical child support coordination must be understood from the county level. We visited one of the three integrated service centers in Dakota County for this study of promising practices. Dakota County is the third most populous county in the state.
Goals, Origins and Implementation
Goals. In Minnesota, the goal of medical support coordination and enforcement of it is to help families become more self-sufficient by obtaining good health insurance coverage for children. And they stress that good coverage, which ideally means combining private coverage and Medicaid for a child, can lower public costs as compared to Medicaid alone, because the private insurance or the non-custodial parent's contribution to the premium for Medicaid's managed care plan, can lower the state's contribution to public coverage premiums. More specifically, the goal of county bonuses is to raise medical child support enforcement and coordination around it to the same level of priority among county child support workers as is establishing paternities and child support orders, by making success in medical child support enforcement fiscally remunerative.
It is important to note that the stated goals of all the participating agencies are in line with the overall goals of the practice itself. The state Department of Human Services (DHS) mission statement says that the Department works with many others to help people meet their basic needs so they can live in dignity and achieve their highest potential. In order to achieve this, the agency emphasizes its partnership with Minnesota's counties. DHS views this partnership as essential to finding innovative solutions to problems, delivering services, and serving taxpayers' desire for cost-efficient and effective government. As shown in Exhibit B, Minnesota is the only county-administered state we visited and one of the few states that require counties to contribute financially to human services administration and benefits.
Officials we interviewed in the Policy and Planning Unit of CSED report that the mission of that agency is to establish paternity, establish support orders, and enforce those orders for children. Every child support order in the state must include an order for basic cash support, one for medical support, and, if appropriate, one for child care support. With respect to medical coverage, officials stressed that the philosophy and goal of the state is to obtain good health insurance coverage for children - that this is the right thing to do for Minnesota's children. But they also stressed that the state can meet the goal of good coverage for children (i.e. obtain some private coverage while leaving open a Medicaid case for that child) and still lower public costs. CSED is developing a new strategic partnership plan, but it is not yet available for public review.
Officials in the Health Care Eligibility and Access unit of the Health Care Administration in DHS also noted that the philosophy and goals of their Administration is to "cover kids" - i.e. children are entitled to good health care coverage. An original goal of Governor Ventura's administration was universal coverage for children. However, dramatic revenue shortfalls in 2002 caused serious mid-year budget cuts, and he was forced to retreat from that goal.
State health care staff also pointed to their strong partnerships with counties on outreach. And they noted a $750,000 annual grants program to community-based organizations for outreach to potential Medicaid and MinnesotaCare enrollees.(47) Interviewees in Health Care Eligibility and Access observed that the mission of covering the maximum number of children possible with health insurance can be overridden in some counties, where worker's traditional role has required them to memorize the eligibility rules and screen clients out from public coverage. To overcome this disparity between the state's philosophy and some counties' philosophies, two efforts are underway. The Health Care Administration has instituted a Steering Committee of County Directors to design a health care program delivery system that improves access and outreach for all Minnesotans. Second, the state plans to fully automate medical assistance eligibility determination in a Web environment over the next year, so that county medical assistance staff no longer have to memorize and exercise the eligibility rules. This move is seen as one that will open county doors wider to eligibility and enrollment in public health insurance.
Origins of Practice. Minnesota's practice of paying bonuses to counties for enforcement of medical child support orders traces its origins to a precedent for state bonuses to counties on other performance standards, and to a 1990 conversation between a Dakota County child support agency official and the state child support director. At that time, counties in Minnesota received bonuses for some of the same accomplishments that states now receive incentive payments from the federal government -paternities established, orders established - as well as for orders modified. No bonuses were paid for medical support. The county official remarked to the state director that the state's policy was for counties to go after medical as well as cash child support, but that counties tended to focus on activities for which incentives were paid. The county official urged that bonuses be added for medical support enforcement in order to get county staff to pay attention to that task and in order to demonstrate to the County Board of Commissioners (appropriators of county funds to child support administration) the return on investment of resources in medical support. The state director approved the idea, directed the department to draft a legislative proposal, and a statute was adopted in 1990.
Implementation. In October 1990, DHS issued instructions(48) to all Boards of County Commissioners, the Director of each County Agency, and the Child Support and the Medical Assistance supervisors in each county, directing them on implementation of the new medical support bonus program. This memo included definitions, methodology for calculating the bonus due, how information would be entered into the child support automated system for counties linked to that system, and how information would be entered manually for counties not linked to the system. It specified how and when counties would report data to the Commissioner of DHS on the number of cases receiving medical assistance as a ratio of the number of cases in which the court has established an obligation to provide medical coverage.
At the state level, coordination occurred between child support and Benefits Recovery staff in the Health Care Administration. This was necessary because the policy called for bonuses to be paid only for children with medical child support orders that are established and enforced after a family had a public assistance case opened. Thus, Benefits Recovery staff had to verify on a quarterly basis that the medical assistance case was receiving private health insurance coverage during the quarterly bonus period.
In Dakota County, meetings were held between the child support director, supervisors and caseworkers and their counterparts who conduct integrated eligibility determinations and case management for the welfare, Medicaid, Food Stamps, Emergency Assistance, and General Assistance cases. Child support staff educated those integrated workers to encourage them to do paper referrals of public assistance cases to child support in instances where the medical assistance application indicates there is a non-custodial parent. In particular, child support staff impressed upon the other programs' integrated workers that as soon as the family is enrolled in public coverage and the application noted a child has a parent not living with them, the case should be referred to child support. This will trigger an investigation into private coverage in order to secure coverage or a premium reimbursement.
In the early years, the state to paid each county a dollar amount per case according to the percentage of cases in which a medical support order was enforced. Counties that exceeded 80 percent of their cases with medical support orders enforced, earned a $25 per case bonus. For counties that successfully enforced between 50 and 80 percent of cases, the bonus amount was $20 per case; and for counties below 50 percent, the per case bonus was $15. This was laid out in the instructions described above. In 1994, the policy was changed to $50 per case across the board.
Current Routine Child Support Operations
In Minnesota, medical support statutes establish that the courts are to order the parent with the better group dependent health and dental insurance coverage or health insurance plan to name the minor child as a beneficiary. Private coverage through a group, employer or union is preferable. However, if dependent health insurance is not available to either the noncustodial or custodial parent, the court may require one of three options for the noncustodial parent: 1) to obtain other dependent health or dental insurance, 2) to be liable for reasonable and necessary medical or dental expenses for the child, or 3) to pay $50 per month to be applied to the medical and dental expenses of the child or to the cost of health insurance dependent coverage. This amount is added to the guideline amount for cash support. If the available dependent insurance does not cover all reasonable and necessary medical or dental expenses of the child, the court may require the noncustodial parent, depending on his or her financial ability, to be liable for a portion or all of these expenses.(49)
The following describes routine operations in Dakota County for either a child support case with a new order, or a case in which the office has just been notified of a new hire(50). It is important to note that this description does not pertain to operations in all counties. In an effort to equitably distribute the responsibilities for medical child support, Dakota County maintains a staff of regular child support workers and two separate medical support specialists who conduct all of medical support coordination and enforcement activities.
To determine if it is appropriate to pursue private coverage, the child support worker reviews the case and determines that certain conditions exist: 1) the noncustodial parent has been ordered to carry insurance for one or more children in the case; 2) no current insurance information exists in the child support automated system; 3) the noncustodial parent has a current employer or is currently paying; and 4) a current address for the noncustodial parent is available in the child support automated records. The worker also assures that appropriate information for insurance is in the current order and any wage information they have available is entered in the system.
Once the child support worker has verified this information, one of the team's two medical specialists sends out a form letter to the noncustodial parent, within two days of a new hire report or within 30 days from the effective date of a court order, reminding him of his court ordered obligation to provide health insurance coverage. This form letter is called the Notice of Medical Support Obligation and Enforcement. The medical specialist also sends a form letter to the employer's human resources contact to determine what insurance if any is available. If reasonable coverage is available but not in place, he/she sends out an order to the employer to enroll the child or children on that insurance. If insurance is in place or obtained, the medical team will verify the information with the insurance company and enter the policy information in the system. The specialist then notifies the regular child support caseworker, gives them the insurance information, and advises them to review the case regularly to watch for job jumping or multiple orders in multiple counties.
However, if there is no insurance available to the noncustodial parent or it does not seem to be available at a reasonable cost(51), the medical team specialist sends the referral back to the child support worker who determines the next step which can include asking the court to modify the medical provisions of the order by ordering an alternative such as a dependent-only policy through an independent insurer or medical support payments to be applied to insurance premiums, medical expenses, or reimbursement for Medical Assistance or MinnesotaCare expenditures.
Current Routine Health Agency Operations
When a parent applies for Medicaid or MinnesotaCare in the Dakota County office, they are given the integrated Minnesota Health Care Programs Application.(52)If they indicate on that application that one or more of their children have a parent not living with the child, they are given or mailed a child support questionnaire to fill out, which they have 30 days to return. The application is processed and approved or denied whether or not the child support questionnaire has been returned. If the application is approved, the Medicaid card will be issued. If the parent never returns the child support information, the child remains eligible for Medicaid but the parent will be removed from the case. If the mother is pregnant, regardless of her compliance with the requirement to cooperate with child support, she will remain eligible for Medicaid through her pregnancy and six weeks following birth.
If appropriate, the child support referral is made right away even before the 30 days of waiting for the custodial parent's information has passed. When the Medicaid or MinnesotaCare application is approved for a household that includes a referral child, an electronic referral is sent to the child support worker via an automated file exchange. If the case is a Medicaid-only public assistance case, the worker will contact the custodial parent to ask if she only wants medical child support enforcement, or full child support services.(53) Very often, the custodial parent will exercise her option to have full child support services.
Once the referral is made, the medical assistance management information system is automatically updated when the child support enforcement agency finds (or enrolls the child in) a heath insurance plan. At this point, the medical assistance worker looks at the policy (i.e. co-payments, coverage, deductibles) to determine if it is appropriate. The medical assistance worker may determine that the dependent should be simultaneously covered by Medicaid or MinnesotaCare and private coverage. If this is the case, the custodial parent will be sent a letter notifying them to use the private coverage as primary and medical assistance as secondary.
Minnesota has increased the value it receives in its health care programs through managed-care purchasing because of savings that result from medical child support. The state contracts for capitated monthly rates with prepaid health plans for Medical Assistance (MA), General Assistance Medical Care (GAMC), and MinnesotaCare recipients. Most of the enrollees in Minnesota's three health care programs are in managed care. State staff annually summarize revenues collected on behalf of children on Medicaid through third party liability. Because the amount of third party payments is continuously tracked for all Medicaid HMO's, the state is able to use that information to negotiate lower capitation rates with HMO's in subsequent years.
Role of Coordination between CSED and DHS. Coordination between state CSED and the Health Care Administration occurs on several additional fronts. When the state legislature in 2000 asked the Department of Human Services to develop recommendations on medical support statutes for the 2001 legislative session, DHS formed a Medical Support Workgroup composed of a wide range of stakeholders. These included representatives from the Health Care Administration (Medicaid and MinnesotaCare) the state Council of Health Plans, the Department of Health, DHS' Benefits Recovery, the Insurance Federation of Minnesota, employers, and the counties. They met several times and developed consensus recommendations in their final report issued in December 2000.
As of the end of 2002, the state was conducting a competition for further study of the role of the child support program in increasing access to medical coverage for children. The RFP seeks, as one of the study's principal outcomes, an analysis of communication and coordination between the child support program and health care assistance programs, and recommendations for improvement.
The state DHS maintains a Joint Committee on Good Cause Exemptions, whose purpose is to review documentation accompanying MinnesotaCare applications for good cause exemptions from the requirement to cooperate with child support enforcement, where the applicant is claiming domestic violence or other appropriate reasons as the grounds for not cooperating. The committee is made up of representatives from the TANF, medical assistance, and child support programs. They meet bi-weekly to rule on good cause claims. Counties maintain similar joint committees to review TANF, Child Care Assistance, and Medical Assistance applications for good cause exemptions.
Finally, respondents from both the health and child support divisions in DHS pointed to the strategic plan that is under development and the greater emphasis that it will place on coordination and partnerships between medical assistance, child support enforcement, child care, employment services, and TANF, and between the state and its county offices.
Funding Sources and Amounts
Funding of the whole child support program's administration in Minnesota comes from a combination of a state appropriation, the 66 percent Federal matching funds allocated to states, much of which the state CSED passes through to counties, federal incentive payments, and the county's own funding appropriated by the Board of Commissioners. The state also passes on much of what it earns in federal incentive funds to the counties, in return for their performance on the OCSE 157 Annual Data Report.
Funding of the state bonus program, for all four types of bonuses, comes from a state appropriation. Since 1996, the Dakota County statistician has been tallying total earnings from all bonuses. In that year, total bonuses were $79,550 and medical support bonus payments totaled $18,050 of that total. By 2001, total bonuses had grown to $145,800 and medical support bonuses represented $22,000 of that total.
At the state level, it was reported that for 2001, the state paid out to counties $3,794,728 in total bonuses, of which $381,150 (about ten percent) was paid for medical support bonuses.
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TexCare is an umbrella campaign, established by the Health and Human Services Commission (HHSC) in concert with the passage of SCHIP legislation in May 2000, that allies several state government agencies with private sector companies, community-based organizations, and Texas' families in order to raise awareness of options for children's health insurance in Texas. It provides education and marketing for SCHIP, Medicaid, and private health insurance, to ensure that Texas' children have health care coverage. The Office of the Attorney General (OAG) and the HHSC maintain a collaborative relationship through the TexCare initiative in order to integrate TexCare outreach and Title IV-D activities. This coordinated effort, referred to as the Title IV-D Outreach Project, is an integral part of the effort of Texas agencies to increase the number of children who have health care coverage.
A secondary piece of Texas' initiative is its comprehensive medical support legislation. For many years, Texas law has contained extensive provisions concerning the medical support portion of a child support obligation. More specifically, it contains a priority scheme that guides the courts in determining the manner in which medical support should be ordered. However, in 2001 the Texas Legislature examined the issue of uninsured children in the state and made several amendments to the Family Code that served to strengthen those provisions.
Organization of Agencies
The Health and Human Services Commission (HHSC) has oversight responsibilities for designated Health and Human Services Agencies such as the Department of Health and the Department of Human Services(54), and administers certain health and human services programs including the Texas Medicaid Program, State Children's Health Insurance Program (SCHIP), and Medicaid waste, fraud, and abuse investigations. While operations and claims processing for the Medicaid (as well as SCHIP) program reside in the HHSC, Medicaid eligibility determination, acute care and EPSDT are located in the Department of Human Services. DHS is also the agency responsible for TANF and Food Stamps.
Entirely separate from HHSC is the Texas Office of the Attorney General (OAG). Led by the Attorney General, the agency has four Deputy Attorneys General for Child Support, General Counsel, Litigation, and Criminal Justice. Under the Deputy Attorney General for Child Support, the key person involved with TexCare is the General Counsel for Child Support.(55) Other units under the Deputy Attorney General for Child Support are the Administrative Law Judge Section, Administrative Operations, Field Operations, Information Technology, Program Monitoring, and Program Operations.
Goals, Origins and Implementation
Goals. The TexCare Partnership, now simply called TexCare(56), is fundamentally about coordination between agencies in order to increase the number of Texas children who have health care coverage. More specifically, the goal of TexCare, as an outreach and education campaign, is to provide access to children's health insurance options by providing information and educating the public about SCHIP, Medicaid, and private health insurance.
The more specific collaboration between the OAG and HHSC has three specific goals: 1) To increase the number if insured children in Title IV-D; 2) To integrate TexCare outreach and Title IV-D activities; and 3) To provide affordable options for low-to-moderate income noncustodial parents.
The amendments made to the Texas Family Code during the 77th Legislative Session were made in order to provide policy guidance to the courts when fashioning medical support orders. (57) The changes were also intended to clarify the various health care options available to the courts and to streamline the medical child support process by including Medicaid and SCHIP in the establishment process and requiring parties to disclose health care coverage details. Previously only private health insurance was considered, and there was no specific disclosure requirement.
Origins. The Texas legislature had already adjourned in May 1997 when SCHIP was passed into law, so legislation concerning the state-designed SCHIP program could not be enacted until the next session.(58)The Texas Department of Health, HHSC, and staff from the Legislature and the Governor's office began designing SCHIP as soon as the Federal legislation was passed, and used the time available before the next legislative session to prepare the state legislative package. Staff contacted other states that had implemented SCHIP earlier to find out what was working and what was not.
The agencies also continuously sought public input through statewide town hall meetings in late 1998. By the time the legislature reconvened, there was enormous grassroots support for the program including major support from the statewide SCHIP Coalition, which consisted of advocates, associations of hospitals, medical and dental personnel, pediatricians and rural health representatives, and legal groups. Public support combined with support from Governor Bush and Lieutenant Governor Perry as well as the possibility of funding the program with the state government's proceeds from the Texas settlement with the tobacco industry created an unusual environment of support for the SCHIP legislation.
In May 1999, the 76th Texas Legislature passed a bill(59) authorizing the creation of SCHIP. The Texas Healthy Kids Corporation that had partnered private health insurance companies and health maintenance organizations to offer private health insurance to low-income Medicaid-eligible children was dissolved and slowly phased out because over 95 percent of its enrollment was estimated to be eligible for SCHIP.
TexCare was created in response to the rollout of SCHIP. Under the TexCare Partnership brand, fifty diverse CBOs were awarded contracts to do outreach across Texas including county health departments, non-profit organizations, religious organizations, and local health clinics. Each organization was given TexCare educational materials that could be adapted to best fit their particular grass-roots effort and the predominant language spoken by their target population. The CBO's worked with SCHIP to set specific goals and performance measures and to propose specific outreach activities. Outreach efforts were launched in early spring 2000, and SCHIP enrollment got into full swing a couple of months later.
Due to interest in the state legislature, there was strong support for outreach efforts specifically for uninsured children from the child support caseload. This involved closer collaboration between HHSC and OAG. The collaboration was not required by the legislation, but it was clear that SCHIP would be relevant to the low-income population in the IV-D caseload. HHSC and OAG had already established a relationship because of the Texas Healthy Kids initiative and the mandatory child support referrals of TANF clients applying for Medicaid. However, a more active partnership was established in 2000, and in March 2001 the two agencies entered into an interagency contract. This formalized the OAG's outreach activities and the specific types of information exchange that would occur including the transfer of the CHIP enrollment file. That allows the OAG to track IV-D children who have been enrolled in CHIP and identify children who do not have health coverage identified.
As part of the state's commitment to addressing the health insurance needs of children, the Legislature amended the Texas Family Code. For many years the priority among Texas courts was to establish and collect on cash support orders, with little focus on medical support. In 2001, the Legislature seriously re-examined provisions and passed new legislation that has made medical support a more visible issue and medical support orders more enforceable.
Implementation. Education for staff in all of the agencies concerning the TexCare and more specifically about the new SCHIP program was the main focus in Spring 2000. Staff from TexCare CBO's, SCHIP, and the OAG began the process of training the judiciary, attorneys, staff involved with child support in HHSC and OAG, medical staff, and parents.
OAG and HHSC staff both received training and provided outreach. TexCare brochures were mailed to all child support field offices for delivery to courthouses, and presentations were made at the annual meetings of both the Child Support Division Managers and the Child Support Division Attorneys. Both agencies also sent staff to do training about TexCare in local child support field offices and local DHS offices. Those offices in turn sent letters to and met with local schools, county health boards, and hospitals. TexCare applications and posters were placed at numerous locations for parents to complete.
An article was published in "In Chambers," a publication for judges, about SCHIP and TexCare. OAG staff made presentations about SCHIP and TexCare to various groups of county judges and at the Title IV-D Masters(60) annual meetings. They also provided family law judges and Title IV-D Masters with SCHIP brochures, sent a direct mailing to all 40 Title IV-D Masters and 100 Family Court Judges, and provided direct localized SCHIP training to Masters and Judges. OAG staff made separate presentations to the Presiding Judges of the Administrative Judicial Regions who in turn provided the information to the judges in their respective regions. OAG staff also worked with the Texas Center for the Judiciary to distribute information about SCHIP and TexCare to all statewide and regional judicial conferences.
For attorneys, an article was published in the State Bar Newsletter, an internet link created from the State Bar website to the TexCare website, and information distributed at the Marriage Dissolution Institute in Fort Worth and at the Advanced Family Law Conference. Local Bar associations received presentations about TexCare, and staff and attorneys working for the Department of Protective and Regulatory Services (the locus of child welfare services in Texas) were given TexCare brochures to give to relative caretakers of foster care children.
The OAG together with the HHSC initiated specific efforts to reach parents of uninsured children and more specifically uninsured children receiving child support also began in earnest. Activities employed included the production and distribution of brochures, airing of radio and television public service spots, articles written for publications read by those constituencies, information packets for distribution at their conferences, direct mailings to each constituency, internet links between TexCare's and each group's web sites, and the opening of application assistance offices via contracts between HHSC and Community-Based Organizations (CBOs) in 30 of Texas' 254 counties. Special outreach attempts were also directed at custodial parents. TexCare applications were also mailed to 80,000 custodial parents from existing child support cases where the noncustodial parent had been ordered to, but not supplied, health care coverage for his children. Some custodial parents objected to this because they felt that the noncustodial parents should provide private health insurance for their child or children. Different outreach methods for custodial parents were employed after this first attempt. For instance, the OAG created TexCare Partnership information packets to send to custodial parents in all new Title IV-D cases.
Changes to the Texas Family Code and Human Resources Code. Texas law has for many years provided a priority scheme for courts to use to determine how to order health care coverage for the child. These five priorities are written into the family code, which was updated and strengthened by the Legislature in light of the new health care coverage options available and the renewed focus on increasing the number of Texas children who have health care coverage. If insurance is available through the obligor's employment or union at a reasonable cost, which is defined in state statute as "the cost of a health insurance premium that does not exceed 10 percent of the responsible parent's net income in a month," the court orders the obligor to add the child to the policy. If the insurance is not available through the obligor's employment or union but it is available at a reasonable cost through the obligee's employment or union, the court orders the obligee to add the child to the policy and the obligor to pay additional support to the obligee for the costs of the insurance. If insurance is not available through either parent's employment or union, the court orders the obligor to provide insurance from another source if it is available at a reasonable cost. If neither parent has access to health insurance, the court orders the custodial parent to apply for benefits under a public medical assistance program (Medicaid and SCHIP). If the child is eligible, the obligor is ordered to pay additional support to the obligee for the cost of the health care coverage. If none of these options are viable, the court orders the obligor to pay the obligee an additional "reasonable amount" each month as medical support.
In accordance with the above changes, additional language stipulated that a parent who fails to provide court-ordered health insurance is liable for the necessary medical expenses of the child regardless of whether the expenses would have been paid by the insurance, and for the cost of insurance premiums that the obligee has incurred on behalf of the child.
In addition, a new provisionamended language relating to the issuance of medical support orders. It established that before a hearing on a temporary or final order, the parties involved in the proceeding must disclose several details concerning the health coverage status of the child. If the child is covered by private health insurance, the parties have to submit the plan information. If there is no private health insurance, the parents must state whether the child is on Medicaid or SCHIP, the cost of the premium, and whether either parent has access to private health insurance at a reasonable cost. If there is insurance in place for the child when rendering a temporary order, the court will, except for good cause shown, order that insurance continue pending a final order. When rendering a final order, except for good cause shown, the court requires that the parent ordered to provide health coverage produce evidence that steps have been taken to secure coverage or that coverage has been secured.
The Legislature also clarified the definition of health in Human Resources legislation as coverage that provides basic health care services (i.e. physician services, office visits, hospitalization, etc.) that may be provided through a health maintenance organization or other private or public organization (including SCHIP), other than medical assistance. (Medicaid).(61) In essence, this change was a technical correction and textual amendment to clarify the legislation's intent. Instead of having a 'Provision for Health Insurance' in the Family Code, there is instead, a 'Provision for Medical Support' that treats health insurance coverage and coverage by medical assistance under the state Medicaid plan differently. These specific types of coverage are to be treated differently and ordered separately by the court using the five priorities.
Further legislation simplified the application process for Medicaid and SCHIP.(62)The critical changes require a single consolidated application for a child under age 19 for Medicaid and SCHIP, permit the application to be submitted by mail instead of through a personal appearance at a department office, and simplify recertification. Before SCHIP was implemented, the medical assistance application was one page front and back, but after the legislative changes requiring SCHIP and Medicaid to be on the same application, the length of the application grew. The previously conceived application had removed questions about income and paternity because focus groups felt it was invasive, but with Medicaid on the same application those questions had to be returned to the form. However, the form change was viewed positively because it streamlined the application process. Previously,when the questions were removed from the application and a case was found to be Medicaid eligible, the applicants were sent a separate form with asset questions, but many people never returned those forms and were never granted Medicaid eligibility. The hope is that fewer applicants will now fall through the cracks, increasing the likelihood of medical child support enforcement.
Taken together, these legislative changes prioritized and strengthened the medical support provisions. The OAG Child Support Division responded to the legislation by creating several new forms for the court process. Every new applicant for child support services, other than custodial parents whose children are on Medicaid, receives the form "Important Information about Children's Health Insurance Program." The "Health Insurance Information Needed for Court" form goes to parties who are scheduled for a court hearing, and the "Health Insurance Availability Form" is to be completed and filed with the court in every legal action where child support or medical support are addressed. This series of forms is meant to establish the health insurance status of every child before the case enters the courtroom, so that the Master can make the most informed decision concerning medical support.
Staff from the OAG put on a seminar in the summer of 2001 at the University of Texas Law School to go over the amendments to Section 154 with IV-D Masters. The new legislation was also discussed at the Advanced Family Law Course and the Annual Title IV-D Master Conference.
Current Routine Child Support Operations
The following describes routine operations for a new child support case, and the interactions that case will have with TexCare. When a custodial parent contacts the OAG Child Support Division or is referred by the Department of Human Services (DHS) in order to establish a child support order, they will be informed about TexCare by child support staff. They may also hear about TexCare because the call center's number is listed on the OAG's call menu. Also, a form entitled "Important Information about Children's Health Insurance Program" is sent to the new applicant, unless they are already receiving Medicaid.
In preparation for taking the child support case to court, the "Health Insurance Information Needed for Court" form and the "Health insurance Availability Form" are sent to both custodial and noncustodial parents. This form is filed with the court every time a child support or medical child support order is addressed in court. In general, many times parents do not fill out the insurance availability form and OAG staff must follow up with the parents in order to establish the state of the child's health coverage before the court date. If the information has not been gathered by the court date, the information will be obtained during the proceedings, sometimes even by calling the employer's human resources department from the courtroom.
When the case comes before the Title IV-D Master, the court uses the five priorities (see Changes to the Texas Family Code and Human Resources Code Section, above) to determine the best solution for health care coverage. In addition to addressing new orders, IV-D Masters also handle requests to modify orders. This may include orders that contain the previous legislation's language that the noncustodial parent must carry the health insurance, and so the medical support issue must be re-visited. IV-D Masters are also seeing more motions for enforcement of medical support since it has become a more visible issue in child support cases. If the noncustodial parent is behind in payments for medical support, the court may determine that the parent is in contempt. There may be a medical arrearage determined and an interest rate of six percent may be added to the amount owed (this rate used to be 12 percent).
Current Routine Health Agency and Contractors' Operations
Custodial parents may apply for TexCare by calling the state's contracted enrollment broker at their call center, by coming in to fill out an application at a local CBO or human services office, by working with CBO staff to fill out an application and send it in, or by downloading the forms off the internet and sending them to the enrollment broker. Broker staff feel that the number of noncustodial parents attempting to apply for coverage has decreased substantially since the new legislation was passed. However, when they receive noncusotidal parent calls, broker staff explain the process and send out an application to the custodial parent if the noncustodial parent provides them with address information for the custodial parent. When the enrollment broker receives the application, it is prepared for eligibility determination and screened for completeness.
All documentation is electronically scanned, so that staff in the enrollment division can continue the eligibility determination process using electronic information instead of paper, which lessens the chance of misplacing verifications. If the application data are complete, the eligibility is calculated through the electronic system. If the application is incomplete, the family is sent a request to provide the missing information to complete the application. If the family returns the necessary information, the eligibility is determined. If there is no response from the family concerning the needed information within 90 days, then the application is "timed out."
If the case appears to be Medicaid eligible, the self-declared asset questions are examined. If it still appears to be Medicaid eligible, the application is forwarded to the Department of Human Services (DHS). This referral occurs through an electronic interface between the enrollment broker's automated system and DHS's automated system. The case information is also sent via an overnight delivery service to local DHS offices across the state based upon ZIP Code, and the local DHS caseworkers make the final Medicaid determination. If DHS determines the applicant Medicaid ineligible due to additional information, the case will be sent back to the enrollment broker's system through the interface.
If the applicant is not Medicaid eligible but is SCHIP eligible, the enrollment broker's system automatically generates a SCHIP enrollment packet that is sent to the family. The family completes the enrollment form and returns it to the broker. If an initial premium/enrollment fee is necessary, the enrollment broker requests that the payment be sent to a bank in Dallas designated to receive these payments. If the payment comes back to the enrollment broker, instead, finance department staff can manually enter the information. The broker receives a file every day from the designated bank in order to match cases with premium payments.
If the child is not eligible for SCHIP or Medicaid, the family is sent a Commercial Insurance Resource Guide published by the Texas Department of Insurance that describes other insurance options. If the child is eligible for SKIP - the insurance program for state employees' children -- the application is referred to the Employee Retirement System of Texas. There is also a box to check on the application if the parent wants a referral to OAG. However, there is currently no system in place for the enrollment broker to actually make an automated referral, but there are plans to fill this gap.
The broker receives a data file monthly from the OAG, assembled by a separate contractor to OAG, containing the names and addresses of the children and custodial parents for cases where the noncustodial parent has been ordered to provide health insurance, but such insurance has been found to be not available because: 1) the employer or union does not provide dependent insurance coverage; 2) the noncustodial parent is ineligible for the insurance coverage; or 3) the insurance is not available at reasonable cost to that parent. The enrollment broker sends these families a letter on OAG stationary explaining that OAG has no records of insurance coverage for the child. The letter supplies a number to call for parents whose children have coverage, so that they can give the policy information to the OAG. For parents whose children are not covered, the packet includes a TexCare application so that the custodial parent may apply for SCHIP and Medicaid.
Local Child Support Agency and TexCare Community-Based Organization Operations. The local site visited for this study was Bexar County, home to one of the three largest cities in Texas - San Antonio - as well as outlying areas that include suburbs and sparsely-settled rural areas. Bexar County has two Title IV-D Masters. One Master travels out to rural areas to hold court sessions, while the other remains in San Antonio. There are six OAG offices in San Antonio itself, one interstate office that handles approximately 12,000 to 16,000, one non-TANF office that handles 10,000 cases or less, and four other large offices that handle between 25,000 and 32,000 cases each. Staffing varies across the large offices but in one of them, thirty child support investigators handle approximately 30,000 cases. Only the Assistant Attorneys General deal with the medical support orders for each case, though, rather than child support investigators.
The medical child support process in Bexar County has been evolving. For many years, the focus was only on cash support payments but now there is a growing emphasis on medical support that reflects the growing emphasis statewide in Texas. Approximately 30 to 50 percent of the IV-D cases that come before the IV-D Masters have private coverage through employment, though this varies by place of residence, and approximately 80 percent of the cases are current or former TANF clients or Medicaid referrals. OAG staff estimate that 90 percent of the noncustodial parents in the caseload are employed but many are with small employers in the area who do not provide health coverage. Frequent job change is also common, and so orders are written with very specific language so that they can be enforced.
OAG staff in San Antonio mentioned several changes that have been positive for the child support process, including the new National New Hire Database that has made the investigation of current employers much easier for cases that involve parents who frequently change jobs. Additionally, the state's wage withholding order form includes language directing the employer to enroll the child on the firm's insurance policy. Staff report that this speeds up the desired outcome of children's health care coverage, because it avoids waiting for the noncustodial parent to take the initiative with the employer's human resources office.
Bexar County is one of a few court systems in the state that actively works with the CBOs contracted by TexCare. Catholic Charities under the supervision of the United Way is one of those contractors to TexCare, and has an office in the courthouse in San Antonio. One IV-D Master allows the CBO staff to work in their courtroom with custodial parents to explain TexCare and to assist them in filling out the applications (if the noncustodial and custodial parent have not been determined to have employer-sponsored coverage available at reasonable cost).
Another IV-D Master prefers that the CBO staff approach custodial parents in the hallway before their case is heard or after the medical support order is complete. So while families sit on benches outside of the courtroom, bilingual CBO staff hand out information to custodial parents and assist parents with the application process. Given enough time, the staff may invite the custodial parent back to the courthouse CBO office to make a preliminary eligibility determination.
Funding Sources and Amounts
There has been no special funding for the coordination and outreach initiatives of TexCare. Legislation stipulated that the state could not use any state general revenue funds for administration unless the state could draw down federal matching funds for each of those dollars. Two exceptions are: 1) an allowance for state general revenue funds to be used for SCHIP coverage of immigrant children residing in the U.S. for less than five years; and 2) an allowance for state general revenue funds to be used for the incremental premium subsidies for children in the state employees' State Kids Insurance Program.
In each year since 2000, the sources of funding have been a combination of Federal funding for Medicaid, SCHIP, and IV-D and their required state matches which are met using tobacco settlement receipts.
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33. The HUSKY Plan, Part B is Connecticut's name for the SCHIP program. Part A is Medicaid. HUSKY is the acronym for Health Care for Uninsured Kids and Youth.
34. Public Act 99-279
35. SES handles court-based enforcement activities such as motions for contempt and enforcing wage withholding and medical support orders, as well as review and modification of orders, processing incoming interstate cases, and operating the Central Registry.
36. Office of Inspector General, Department of Health and Human Services. June 1998. Review of Availability of Health Insurance for Title IV-D Children. A-01-97-02506. Boston, MA: Office of Audit Services.
37. Public Act 97-1
38. Subsection (g) in section 46b-215a-2a
39. State of Connecticut, Commission for Child Support Guidelines. "Child Support and Arrearage Guidelines." Effective August 1, 1999.
40. PA 99-279, Section 46b-215, Sections 28, 29, 30, and 31
41. SES handles court-based enforcement activities such as motions for contempt and enforcing the wage withholding and medical support order, as well as review and modification of orders, processing incoming interstate cases, and operating the Central Registry. They would also handle license revocations when applicable, though we were told SES rarely uses this enforcement tool.
42. Non-IV-D cases are handled by judges.
43. By October 1, 2001, all states were required to implement the Federal Office of Child Support Enforcement's National Medical Support Notice (NMSN), unless the state needed to pass enabling legislation. NMSN will standardize the information to be shared, timelines, and roles and responsibilities for sharing health insurance information between the child support agency, employers, and health plan administrators. Subsequent to our early September visit to Connecticut, BCSE planned to initiate on October 1 the National Medical Support Notice (NMSN). The state BCSE has contemplated many changes to process and paper flow necessitated by NMSN implementation, and coordinated with the courts, SES, HUSKY officials, and the enrollment broker, over how it will work.
44. In HUSKY, Level B1 coverage is premium free with modest co-payments to families of four with incomes between $32,653 and $41,477. HUSKY Level B2 coverage requires a $30 per child and $50 per family monthly premium and modest co-payments and is available to families with incomes between $41,478 and $52,950. Level B3 coverage costs between $137 and $200 per month per child in premiums, plus co-payments, and is available to families with incomes over $52,950.
45. The Magistrates informed us that while their caseloads have increased dramatically since 1991, and pro se cases have increased 50 percent in that time, there has been no authorization to increase the number of Family Support Magistrates since 1991. One Magistrate estimated that if he were to consider everything he was supposed to consider on a given case, and think it all through before ruling, he would get through six cases per day. Instead, for example, he hears 75 to 80 requests for modification, alone, on Fridays.
46. The state provides health insurance coverage for children under age two living at or below 280 percent of the federal poverty level (FPL) and for children age two and up and their parents living at or below 275 percent of FPL, through their MinnesotaCare program. This program began in 1992. As a result, and because the program could not be grandfathered into SCHIP, the state has a very small number of children enrolled in SCHIP.
47. Minnesota had a subsidized health insurance program for the low-income population who cannot afford many private policies well before the enactment of SCHIP. Called MinnesotaCare, this program began in 1992. As a result, and because the program could not be grandfathered into SCHIP, the state has a very small number of children enrolled in SCHIP. In 2000, the latest year for which data were available, there were 363,605 enrollees in Medicaid, 123,365 in MinnesotaCare, and 24 in SCHIP. Thus, this report refers frequently to MinnesotaCare - a SCHIP-like program - rather than SCHIP.
48. Instructional Bulletin #90-75G
49. Minnesota Statute 518.171 Medical Support
50. The PRISM system, the automated child support case and financial management system, automatically notifies workers of new hires, because there is a data match between the state's New Hire Database and PRISM.
51. An exact measure of reasonable cost is a county decision. In Dakota County, workers consider it to be 5 percent of gross monthly income.
52. All counties take applications for Medicaid on a single, integrated application form for all medical assistance programs in Minnesota. With MinnesotaCare, counties can opt to take applications in the county service center or not. Dakota County is one of approximately 35 of the 87 counties in the state that have opted to take applications. In the remaining 52 counties, the applicant mails the application to the state office. If the applicant is found eligible for MinnesotaCarte and there is noncustodial parent indicated, the applicant is referred back to county medical staff to initiate the coordination with child support enforcement for private medical child support.
53. The state DHS maintains a Joint Committee on Good Cause Exemptions, whose purpose is to review documentation accompanying MinnesotaCare applications for good cause exemptions from the requirement to cooperate with child support enforcement, where the applicant is claiming domestic violence or other appropriate reasons as the grounds for not cooperating.
54. The Texas Health and Human Service Agencies include not only the Texas Health and Human Services Commission and the Department of Health, but also the Department of Human Services, Department of Mental Health and Mental Retardation, Department of Protective and Regulatory Services, Department on Aging, Commission for the Blind, Commission for the Deaf and Hard of Hearing, Commission on Alcohol and Drug Abuse, Rehabilitation Commission, Interagency Council on Early Childhood intervention Services, and Health Care Information Council.
55. The person holding this position for the past several years and integrally involved with the TexCare Partnership departed her position the week before our visit. However, her successor has been with OAG for many years, and the Deputy General Counsel was closely involved with the predecessor General Counsel and with the successor. She and the new General Counsel participated in our interviews.
56. TexCare was originally called the TexCare Partnership. It was recently changed because the 'Partnership' part of the name seemed to be confusing to consumers.
57. Amendments made changes to Sections 101.015, 154.181, 154.182, 154.188, and Section 32.025 of the Human Resources Code.
58. The Texas legislature convenes in alternating years, not annually.
59. Senate Bill 445
60. Special Court Masters, rather than judges, hear all IV-D child support cases in Texas. Masters are appointed, while judges are elected.
61. HB 1365, Section 101.015
62. SB 43 amended Section 32.025
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