Library: Policy

340:25-5-168. Establishment of medical support

Revised 9-15-20

(a) Scope and applicability. Oklahoma Department of Human Services (DHS) Child Support Services (CSS) refers to federal and state law for establishment of a medical support order, per:

(1) Section 666 of Title 42 of the United States Code (42 U.S.C. § 666) and 25 U.S.C. § 1603(12);

(2) Sections 302.33, 302.56, 303.7, 303.30, and 303.31 of Title 45 of the Code of Federal Regulations (45 C.F.R. §§ 302.33, 302.56, 303.7, 303.30 & 303.31); and 42 C.F.R. § 433.152;

(3) Section 6058A of Title 36 of the Oklahoma Statutes (36 O.S. § 6058A), and 43 O.S. §§ 112, 118-118I, 118.2 and 119, and 56 O.S. § 237. • 1

(b) Medical support provision of child support order. A child support order established by CSS must contain a medical support provision. • 2

(1) deducts from the total insurance premium, the cost of coverage for the parent;

(2) deducts from the total insurance premium, the cost of coverage for any other adults in the household, when that cost information is available;

(3) divides the remainder by the number of dependent children covered; and

(4) multiplies the amount per child by the number of children in the child support case under consideration. • 3 & 4

(d) Standards for medical support provision. When choosing a medical support provision, CSS requests the court to apply the standards in (1) through (3) of this subsection.

(1) Health insurance must be reasonable in cost, meaning that the pro rata share of the actual out-of-pocket premium cost paid for the child(ren) by the insured does not exceed five percent of the gross income of the parent ordered to provide health insurance. • 3, 5, & 6

(2) Health insurance must be accessible, meaning the health care providers must be available to meet the child(ren)'s individual health care needs, and must be located no more than 60 miles one-way from the primary residence of the child(ren). • 5

(3) Health insurance must provide coverage for both routine and major medical expenses including, but not limited to: preventive care, office visits, hospitalization, and medication coverage in compliance with the Oklahoma Insurance Department, per Oklahoma Administrative Code (OAC) 365:10-5-3(14) and OAC 365:10-5-5(f). Limited Insurance Coverage, per OAC 365:10-5-5(k) does not satisfy this requirement. Annual deductibles must be reasonable and relate to the medical circumstances of the child(ren). • 5

(e) Exceptions to standards for medical support provision. When the parents agree or it is otherwise appropriate, CSS requests the court make an exception to the standards for health coverage when the:

(1) reasonable cost of health insurance exceeds five percent of the gross income of the parent ordered to provide health insurance; or

(2) closest insurance provider exceeds 60 miles one-way from the primary residence of the child(ren).

(f) Selection of health care coverage. CSS requests the court consider the cost, quality, and accessibility of health care coverage available to the parties when entering a medical support order.

(g) Health coverage preference. When health coverage meeting standards in (d) of this Section is available to both parents, CSS requests the court give priority to the preference of the custodial person (CP).

(h) Applicability of cash medical support. CSS requests a cash medical order by the obligor, when:

(1) the court determines an order for health insurance is inappropriate due to family violence concerns; or

(2) the only health care plan available for the child is a governmental medical assistance program or health plan, such as SoonerCare (Medicaid); or

(3) there is no health care plan available for the child(ren).

(i) Cash medical support.

(1) When cash medical support is applicable, CSS requests the court order cash medical support to be paid by the obligor, until the obligor enrolls the child(ren) in accessible insurance coverage and provides proof of enrollment to CSS and the CP.

(2) CSS refers to the Cash Medical Income Guidelines Table as found in the child support computation form prescribed by CSS and published by the Administrative Office of the Courts on the Oklahoma State Courts Network site, per 43 O.S. § 120 to determine the cash medical support amount.

(3) CSS computes a cash medical order by applying the Cash Medical Income Guidelines Table, using the gross income for the noncustodial (NCP) of the child in the case under consideration and the number of children in the instant case.

(A) When the NCP's gross income is at or below the income amount for the number of children in the case, CSS requests the court order a cash medical order at $0 per month.

(B) When the NCP's gross income exceeds the income amount for the number of children in the case, CSS computes the requested cash medical order by:

(i) multiplying the amount of $115, representing the average monthly cost of health care for an uninsured child(ren), by the number of children in the case not covered by insurance; and

(ii) prorating the result by the percentage of income for each parent.

(D) CSS does not request the court set cash medical support against a parent who has at least 182 overnights.

(4) Unless the parties agree or the court orders a greater amount, the prorated cash medical support amount must not exceed five percent of the gross income of the parent who is ordered to pay cash medical support.

(5) CSS seeks cash medical support only as part of a prospective order for child support. CSS does not include a cash medical support amount in a judgment for support for a prior period, per OAC 340:25-5-179.1.

(6) In a child support modification action, CSS requests a cash medical support order be effective the same date the modified child support amount is effective, unless the parties agree to a different date or the change in health coverage cost or availability occurred on a later date.

(7) In a multiple case action, when the monthly child support amount in the combination child support computation form exceeds 20 percent of the NCP's gross income, CSS may request a deviation to set cash medical support at $0 per month in the individual computation forms as applicable.

(j) Medical support for DHS adopted children. CSS does not request health insurance or cash medical support for children who are adopted through DHS Adoption Services. CSS requests a medical support order reflecting that the child(ren) receive SoonerCare (Medicaid) through the adoption plan. The parties may agree to cover the child(ren) on health insurance.

(k) Termination of cash medical support.

(1) When CSS receives notice the parent ordered to pay cash medical support enrolled the child(ren) in health insurance, CSS sends a Notice of Proposed Termination of Cash Medical Support to all parties in the case by regular mail. When a party believes the child(ren) is not covered by accessible health insurance, a party may request a review of the termination of cash medical support within 10-calendar days from the date of mailing of the notice. • 8

(2) When a party requests a review to contest the Notice of Proposed Termination of Cash Medical Support, CSS reviews the case within 10-calendar days of receipt of the request and determines if termination of cash medical support is proper based on information provided by the contesting party. CSS notifies the parties of the review decision. • 8

(3) When the parties disagree with the review decision, the parties have 15-calendar days from the date of mailing the review decision to request a hearing on the termination of cash medical support.

(4) CSS files a Notice of Termination of Cash Medical Support with the proper court when no party requests a:

(A) review within the 10-day time period; or

(B) hearing after CSS notifies them of the review decision.

(5) CSS does not proceed with a separate termination of cash medical support when the child support and medical support order is modified within 30-calendar days of notification that the child(ren) is enrolled in health insurance.

(6) When a cash medical support order is terminated within a modification action, CSS requests the termination become effective the date of filing of the Motion to Modify or the date, if later when the child was actually enrolled in the insurance.

(l) Reinstatement of cash medical support.

(1) CSS seeks reinstatement of the cash medical order when:

(A) a child support court order previously ordered the NCP to pay cash medical support until insurance was available;

(B) insurance became available;

(D) the insurance subsequently lapsed. • 9

(2) CSS uses one of the processes listed in (A) or (B) of this paragraph to seek reinstatement of the cash medical order:

(A) Modification. CSS seeks modification of the child support order and reinstatement of cash medical support, per OAC 340:25-5-198.1 and OAC 340:25-5-198.2 when:

(i) the child support order that provided for cash medical support was modified to include credit for insurance premium costs; or

(ii) there is another material change of circumstance in addition to the lapse of health coverage.

(B) Expedited Process. When (A) of this paragraph does not apply, CSS uses an expedited process to reinstate the cash medical support. CSS uses the expedited process when there is an address of record for the obligor.

(3) CSS initiates a reinstatement of cash medical support when it receives notice the parent whose cash medical support was terminated due to the enrollment of the child(ren) in health insurance has allowed the coverage to lapse. CSS sends a Notice of Proposed Reinstatement of Cash Medical Support to all parties in the case by regular mail. When a party believes the child(ren) is covered by health insurance, a party may request a review of the reinstatement within 10-calendar days of the date the notice was mailed.

(4) A party may file a written objection to the reinstatement of cash medical support and submit it to CSS with supporting health care coverage documentation. CSS reviews the case within 10-calendar days of receipt of the objection and determines if reinstatement of cash medical support is proper based on the information provided by the contesting party. CSS provides the CP and the NCP with written notice of the review decision.

(5) When the parties disagree with the review decision, they have 15-calendar days from the date of the review decision to request a hearing.

(6) CSS files a Notice of Reinstatement of Cash Medical Support with the proper court when no party requests a:

(A) review within the 10-calendar day time period; or

(B) hearing after CSS notifies them of the review decision.

(m) Fixed medical costs. When the parties agree or the court orders, CSS includes the total monthly fixed medical costs in the child support guidelines computation. When the obligor's share of fixed medical costs exceeds five percent of the obligor's gross income and the parties do not agree to exceed the five percent standard, CSS requests the court determine the monthly amount of fixed medical costs included in the current child support order. • 10

(n) Indian Health Services (IHS).

(1) When a child support order that provides for the enrollment of a child(ren) in IHS does not meet the standards in (d) of this Section, CSS seeks an order for either or both parents to secure another type of health care coverage besides IHS for the minor child(ren).

(2) CSS does not request cash medical support when a child(ren) is receiving IHS.

(o) Notification requirements. The NCP and the CP must notify CSS in writing within 30-calendar days after:

(1) health insurance becomes available;

(2) the cost of existing health insurance changes; or

(3) other provisions of existing health insurance change.

(p) Modification request. When a child support order exists, CSS considers a request to establish a medical support order as a request for modification of the order, per 43 O.S. § 118.1. CSS seeks a medical support order in a tribunal that has jurisdiction to modify the child support order.

INSTRUCTIONS TO STAFF 340:25-5-168

Revised 9-15-20

1. In cases referred to Oklahoma Human Services Child Support Services (CSS) by an Adult and Family Services (AFS) worker, CSS provides all appropriate Title IV-D services, unless the person requests medical enforcement only. CSS opens a full-service case when the AFS worker enters Y in the D8 block on the ED screen on the PS2 automated system.

2. When the parties state health coverage is available, but there is no proof that it is in effect at the time the order is entered, CSS seeks a temporary medical support order until proof of coverage is received.A final order may then be obtained.

3. CSS staff determines the out-of-pocket cost for health insurance by subtracting any amount paid by the employer through a benefit allowance from the premium amount paid by the insured.

4. (a) When the cost of the insurance premium for other adults in the household is included with the cost for the child(ren) and information is not available to determine a separate amount for the other adults, CSS staff uses this premium cost to determine the amount per child.

(b) For example, the total health insurance premium is $275. The portion of the premium for the parent carrying the insurance is $75. The portion of the premium for the other adults in the home is unknown and cannot be determined. The number of children covered is four. The number of children in the child support case is three. The cost of the insurance premium for each child in the child support case is $50 ($275 - $75 = $200 ¸ 4 = $50 x 3 = $150).

5. Examples of when health insurance does not meet the standards for health coverage include when the noncustodial parent has:

(1) gross income of $1,733 a month and has an employer-sponsored plan that would cost the parent $225 a month in out-of-pocket premium costs for three children in the case under consideration. CSS does not consider the contribution to the premium that might be made by another person or other entity. Since $225 is more than 10 percent of the $1,733, the cost of the insurance is not considered reasonable;

(2) available health coverage, but the nearest network provider is 60 miles one-way from the primary residence of the child(ren); and

(3) available health coverage that only meets the definition of a:

(A) Limited Benefit Health Insurance Coverage; or

(B) policy with an excessive deductible and co-payment amount.

6. When applying the reasonable cost standard, CSS staff uses the parent's gross income at the time the order is established to determine whether the actual premium cost of available coverage for the child(ren)'s portion only exceeds five percent of the parent's gross income.

7. When a parent's spouse provides the health care coverage for the child, CSS attributes the prorated dependent premium in the child support computation to the parent whose spouse is providing the coverage.

8. (a) CSS staff terminates cash medical support:

(1) when a request for review is received. CSS staff uses the first day of the second month following the date of the Notice of Proposed Termination of Cash Medical Support as the termination date for the cash medical support. Example: When a Notice of Proposed Termination is issued on September 14, the termination date for the cash medical support is November 1; or

(2) at an earlier date when the parties agree health care coverage is in place and agree to an earlier date.

(b) When CSS staff denies a request for review of termination of cash medical support and no party requests an administrative review within 15-calendar days CSS staff:

(1) updates the child support case information on the Oklahoma Support Information System (OSIS) to remove the cash medical support amount in the current monthly child support obligation; and

(2) generates an amended Notice of Income Assignment to the employer that does not include the cash medical support amount.

(c) Examples of cases when termination of cash medical support is appropriate include when CSS staff receives notice that:

(1) a parent's employer enrolled the child in health insurance;

(2) the child is enrolled in health insurance through a private insurance policy or group health insurance through another source, such as a third party custodian or parent's spouse; or

(3) the child is enrolled in alternative coverage, such as Indian Health Services (IHS) or Defense Eligibility Enrollment Reporting System (DEERS).

(d) Examples of cases when termination of cash medical support is not appropriate include when CSS staff has information that:

(1) a parent's employer has health insurance available, but staff has not received notice that the employer enrolled the child in health insurance; or

(2) the child may be eligible for IHS services or DEERS, but staff has not received notice that the child is enrolled in this alternative coverage.

(e) When there is an intact family, CSS updates the CSS automated system to stop both current support and cash medical from accruing without the necessity of filing a notice of proposed termination of cash medical support.

9. (a) CSS staff uses the first day of the second month following the date of the Notice of Proposed Reinstatement of Cash Medical Support as the reinstatement date for the cash medical support. Example: The proposed reinstatement notice is printed on September 14. The reinstatement date for the cash medical support is November 1.

(b) When CSS staff denies a request for review of reinstatement of cash medical support and no party requests an administrative hearing within 15‑calendar days:

(1) CSS staff updates the child support case information on OSIS to add the cash medical support amount to the current monthly child support obligation; and

(2) generates an amended Income Withholding Order to the employer, including the cash medical support amount.

10. When there are multiple custodial persons (CP) and it is not clear which CP is incurring a fixed medical expense, CSS staff inquires of all CPs.After obtaining the information, CSS staff creates or updates the obligation(s) to ensure the fixed medical support portion of the current monthly support obligation is distributed to the CP incurring the fixed medical expense.When staff is unable to ascertain the correct CP, the fixed medical support follows the child, per Oklahoma Administrative Code 340:25-5-133, until otherwise ordered by the court.When CPs disagree as to whom the fixed medical support is owed, CSS staff requests a court determination.