21 Million Children’s Health:
Our Shared Responsibility

The Medical Child Support Working Group’s Report

APPENDIX C:
Legislation

Legislative History of Major Medical Support Provisions

1974:  Pub. L. 93-406 The Employee Retirement Income Security Act of 1974 (ERISA).

Regulated most privately sponsored pension plans and health benefit plans. Covered such health benefit plans regardless of whether benefits are provided through the purchase of insurance or from the sponsor's or the plan's general assets. Imposed health plan benefit requirements related to information which must be provided to plan participants and beneficiaries; internal procedures for determining benefit claims; and standards of conduct of those responsible for plan management. Included a broad "preemption" provision, which provides that unless one of the statutory exceptions applies, the provisions of ERISA supersede any State laws that relate to any covered plan.

1975:  Pub. L. 93-647 The Social Services Amendments of 1974.

Created Title IV-D of the Social Security Act to establish the Child Support Enforcement Program, in which the Secretary of Health, Education, and Welfare (now Secretary of Health and Human Services) is charged with the responsibility for overseeing the operation of the new program, including the following major functions: establishing a parent locator service; establishing standards for State program organization, staffing, and operation; reviewing and approving State plans; providing technical assistance to States; maintaining records of program operations, expenditures, and collections; and submitting an annual report to Congress. Primary responsibility for direct program operations-including locating absent parents, establishing paternity, and securing support for individuals receiving AFDC-was assigned to States. Applicants and recipients for AFDC were required to assign their rights to child support to the State as a condition of eligibility.

1977:  Pub. L. 95-142 The Medicare-Medicaid Anti-Fraud and Abuse Amendments of 1977.

Established a medical support enforcement program under which States could require Medicaid applicants to assign to the State their rights to medical support. State Medicaid agencies allowed to enter into cooperative agreements with any appropriate agency of any State, including the IV-D agency, for assistance with the enforcement and collection of medical support obligations. Incentives were made available to agencies making child support collections for States and to States securing collections on behalf of other States.

1984:  Pub. L. 98-378 The Child Support Enforcement Amendments of 1984.

Mandated that all States enact statutes providing for such improved child support enforcement mechanisms as: (1) mandatory income withholding procedures; (2) expedited processes for establishing and enforcing support orders; (3) State income tax refund interceptions; (4) liens against real and personal property; (5) the formulation of guidelines for determining appropriate child support obligations and the distribution of guidelines to judges and other individuals with authority to establish obligation amounts; (6) establishment of medical support awards in addition to cash support awards; (7) allowing paternity actions any time prior to a child's 18th birthday; and (8) submission of reports of support delinquency information to consumer reporting agencies.

1988:  Pub. L. 100-485 The Family Support Act of 1988.

Judges and other officials required to use State guidelines for support awards unless they are rebutted by a written finding that applying the guidelines would be unjust or inappropriate in the case. Required States to: (1) meet Federal standards for the establishment of paternity beginning in FY 1992; (2) require all parties in a contested paternity case to take a genetic test upon request of any party; and (3) develop a Federally-approved, single, statewide automated data processing and retrieval system with the capacity to process IV-D cases statewide by October 1, 1995. (This deadline was later extended to October 1, 1997.) States were also encouraged to adopt a simple civil process for voluntarily acknowledging paternity and a civil procedure for establishing paternity in contested cases.

1988:  Pub. L. 101-239 The Omnibus Budget Reconciliation Act of 1989.

Made permanent the requirement that Medicaid benefits continue for four months after a family loses AFDC eligibility as a result of collection of child support payments.

1993:  Pub. L. 103-66 The Omnibus Budget Reconciliation Act of 1993 (OBRA '93).

Amended Title XIX of the Social Security Act by adding §1908 to require States to have laws prohibiting employers and insurers from denying enrollment of a child under a parent's family health coverage plan due to various factors such as: the child being born out of wedlock, the child was not claimed as dependent on the parent's Federal income tax return, or the child does not live with the parent or in the insurer's service area. State Title XIX agencies were permitted to garnish wages, salary, or other employment income, and withhold State tax refunds from any person who is legally required by court or administrative order to offer coverage of health services costs to a child eligible for medical assistance under Title XIX and who has received payment from a third party but has not reimbursed either the other parent or guardian of the child or the provider of the services.

Also amended ERISA by adding §609 (29 U.S.C. §1169) which, among other things, requires covered group health plans to provide benefits in accordance with applicable requirements of "medical child support orders" that satisfy the statutory requirements contained in this section related to "qualified medical child support orders" (QMCSOs). For purposes of §609, a "medical child support order" was defined to mean a judgment, decree, or order issued by a court of competent jurisdiction which provides for child support with respect to a child of a health plan participant or for health coverage of a child of a participant, or which enforces a law relating to medical child support described in §1908 of the Social Security Act with regard to a group health plan.

1996:  Pub. L. 104-193 The Personal Responsibility and Work Opportunity Act of 1996.

Established the requirement that States implement further expedited administrative procedures for establishing paternity and for establishing, modifying, and enforcing support obligations and develop and expand additional databases of State IV-D agencies. Also expanded the authority of IV-D agencies to act without obtaining an order from a judicial or administrative tribunal and required IV-D agencies to expand their use of administrative enforcement remedies, including income withholding, seizure of funds, statutory liens, voiding of fraudulent property transfers, license suspension, repayments, work requirements, credit bureau reporting, and passport revocations. All IV-D orders were required to include a provision for health care coverage. (Previously, IV-D agencies were required to simply petition for the inclusion of medical support in new and modified support orders when health care coverage was available to the noncustodial parent through employment-related or other group family health coverage.) States were also required to provide for a simple administrative process for enrolling a child in a new health plan involving the use of a notice of coverage, which operates to enroll a child in a new employer's health plan.

Also amended §609(a) of ERISA to expand the definition of "medical child support orders" to permit certain administrative orders to be considered QMCSOs if applicable requirements in §609(a) are satisfied. (This expanded definition permitted administrative agencies to issue QMCSOs, whereas previously only courts were allowed to do so.)

1997:  Pub. L. 105-33 The Balanced Budget Act of 1997.

Created Title XXI of the Social Security Act to establish the State Children's Health Insurance Program (SCHIP), which provides funds to States to enable them to initiate or expand the provision of child health assistance to uninsured children of low-income families. Established a flexible administrative framework that enables States to operate their respective SCHIP programs as an extension to the Medicaid Program, as a separate entity, or as a combination of these two approaches.

1998:  Pub. L. 105-200 The Child Support Performance and Incentive Act of 1998.

Mandated that several actions be taken to improve medical support enforcement in the child support enforcement program, including: (1) the joint establishment of a Medical Support Working Group by the Secretaries of HHS and Labor to identify impediments to the effective enforcement of medical support by State IV-D agencies and submit to the Secretaries of HHS and Labor a report containing recommendations addressing identified impediments; (2) the joint development and promulgation of a National Medical Support Notice by the Departments of HHS and Labor, to be issued by State IV-D agencies as a means of enforcing health care coverage provisions contained in child support orders; (3) the joint development and issuance by the Departments of HHS and Labor of Federal interim and final regulations which include appropriate procedures for the transmission of the National Medical Support Notice to employers by State IV-D agencies; and (4) the joint submission by the Secretaries of HHS and Labor of a Report to Congress that addresses recommendations made by the Working Group and includes an assessment of the National Medical Support Notice. In addition, the HHS Secretary, in consultation with State IV-D Directors and representatives of children potentially eligible for medical support, was directed to develop a performance measure based on the effectiveness of States in establishing and enforcing medical support obligations and to make recommendations for the incorporation of the measure in a revenue neutral manner into the Child Support Incentive Payment System, no later than October 1, 1999.

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Last updated: 11/17/00