Health insurance, cash medical support and uninsured costs

The basic child support figure from a state’s schedule or formula is meant to cover the everyday cost of raising a child: housing, food, clothing, transportation and routine health spending. It usually does not include the premium for the children’s health insurance, and in most states it leaves out large or recurring medical bills too. Those are handled as separate parts of the order, and they can move the guideline amount more than parents expect.

This guide covers the three parts: the premium, cash medical support and uninsured costs. It explains how states fold each into the worksheet and what to gather before you run an estimate. The main child support calculator has a health insurance field under More options for every state where the premium changes the result.

What federal rules require

Federal law sets the frame. Every state’s guidelines must address how the parents will provide for the child’s health care needs through private or public health care coverage, cash medical support, or both. That requirement is in 45 CFR 302.56.

A second regulation, 45 CFR 303.31, applies to cases the state child support agency handles. It treats coverage or cash medical support as reasonable in cost when it doesn’t exceed 5% of the responsible parent’s gross income, unless the state adopts its own income-based standard. Many states have done exactly that.

Two practical points follow. An order normally says who carries coverage, not only how much money changes hands. And coverage isn’t required at any price: if a policy costs more than the state’s reasonable-cost standard, the order can rely on other coverage or on cash medical support instead.

How states handle the premium

Only the children’s part of the premium counts. If a parent’s plan covers that parent, a new spouse and the children, worksheets typically divide the premium by the number of people covered, or use the extra cost of adding the children, and count only that part. States then use one of four methods.

Added and shared by income. This is the most common method. The children’s premium is added to the basic obligation, divided between the parents by income share, and the parent who pays it is credited. Among the states this site covers, it is used in 37 states.

Deducted from income. In California, Connecticut, Massachusetts, New Hampshire, North Dakota, Ohio, Rhode Island, Texas, Vermont and Wyoming, the rules work mainly through income: a premium a parent pays comes off that parent’s income before the guideline is applied. Some of these states also add a premium the receiving parent pays.

Both. In Michigan and Oregon, the rules combine the two, deducting one kind of coverage cost from income and sharing the children’s premium.

Split equally. In Alaska and Utah, each parent pays half of the children’s premium, whatever their incomes.

The method matters. Take a family where Parent A earns $60,000 a year, Parent B earns $40,000, and their two children live mainly with Parent B. In Colorado, the guideline amount is $1,017 a month. If Parent B also pays $300 a month for the children’s coverage, it becomes $1,197 a month, because Parent A now pays an income share of the premium. In Utah, the same family’s figure moves from $872 to $1,022 a month, because each parent pays half. In Ohio, where premiums work through income and cash medical support is added to every order, it moves from $1,036 to $1,055 a month.

Where the second column says “No”, uninsured costs are usually still shared, but as they arise under the order rather than through the monthly figure.

Cash medical support

Cash medical support is money ordered toward the cost of coverage or toward medical costs insurance doesn’t pay. The federal definition covers payments toward public coverage too. It tends to come up in three situations: no parent has coverage available at a reasonable cost, the child is covered by a public program, or the other parent carries coverage and the court wants the paying parent to contribute toward it.

States set it very differently. Ohio adds cash medical support of $510.21 per child a year to every order, split by income share. Oklahoma uses $115 per child a month for uninsured children when the paying parent’s income is above its threshold table. Most other states set no fixed figure and leave the amount to the court or the agency.

Medicaid, CHIP and marketplace coverage

Many children are covered by Medicaid or the Children’s Health Insurance Program, and some families buy coverage through the health insurance marketplace. Child support rules don’t take sides on which kind of coverage is better. Federal regulations count public coverage as health care coverage, so a child on Medicaid can meet the order’s coverage requirement, and the order can still deal with uninsured costs and, in some states, a contribution toward the public coverage.

Marketplace plans raise a different question: whether the premium that counts is the full price or the price after any premium tax credit. Worksheets generally use what a parent actually pays for the children’s coverage. If a subsidy or employer contribution lowers the cost, use the lower figure, and keep the plan statement that shows how it was split.

Uninsured costs and yearly thresholds

Copays, deductibles, prescriptions, orthodontics, therapy and vision care are where disagreements most often start. Many state schedules already include a modest yearly amount of ordinary uninsured spending per child. Costs above that are shared separately, usually by income share.

Some states put a dollar threshold in the rules. In Maryland, for example, uninsured costs above $250 in a calendar year are added and divided by income. In Massachusetts, the receiving parent pays the first $250 a year of routine uninsured costs for all the children, and the court allocates the rest. Among the states this site covers, a yearly threshold of this kind is part of the rules in Alaska, District of Columbia, Kentucky, Maryland, Massachusetts, Montana, New Jersey, South Dakota and Vermont.

When a cost is predictable and recurring, such as a monthly prescription or weekly therapy, several states let it be added to the monthly amount. One-off costs are usually reimbursed as they happen. Orders often set a deadline for sharing receipts and for repaying the other parent’s share; keeping copies of bills, explanation-of-benefits statements and proof of payment avoids most disputes.

Getting the numbers right

Before running an estimate, gather the plan’s premium breakdown (employee only, employee plus children, family), the name of the parent who pays it, and a year of uninsured costs if they are significant. Enter the children’s share only.

A change in coverage can be grounds to revisit an order. Federal rules make the need to provide for a child’s health care an adequate basis to start a review of an agency-enforced order, even if the support amount itself wouldn’t change much. If coverage was lost or a premium rose sharply, see how to modify a child support order and compare figures with the modification calculator.

Health care is one of several add-ons. Work-related child care is handled in a similar way, covered in work-related childcare costs, and the bigger picture of how the base figure is built is in how child support is calculated. Courts can deviate from the guideline amount when the usual split doesn’t fit a family’s medical situation.