PRIA, Government Policy, Made Personal

Summary

Requires states to have rules that protect a child’s health coverage when a parent must provide it. Insurers cannot refuse to add a child because the child was born out of wedlock, is not claimed on the parent’s federal tax return, or does not live with the parent or in the plan’s service area. If a court or agency orders a parent to provide coverage and that parent can get family coverage, the insurer must let the child be added at any time, must enroll the child if the other parent or the State asks and the required parent does not, and may not drop the child unless the order has ended or the child will have comparable coverage starting no later than the drop date. The same rules apply to employers that offer family coverage, except an employer may drop coverage if it stops offering family coverage to all employees. Employers must withhold the employee’s share of premiums and pay the insurer, but not more than the limit in section 1673(b) of title 15; the Secretary may allow withholding of less in certain cases. Insurers must treat a State agency that takes over a parent’s rights the same as any other agent. If a child is covered under a noncustodial parent’s plan, the insurer must give the custodial parent needed information, allow the custodial parent (or a provider with the parent’s OK) to file claims without the noncustodial parent’s approval, and pay those claims directly to the custodial parent, the provider, or the State. The State may garnish wages or take State tax refunds from anyone ordered to provide coverage who was paid by a third party for the child’s care but did not use that money to reimburse the correct parent, guardian, or provider. “Insurer” includes group health plans, HMOs, and service benefit plans under section 1167(1) of title 29.

Title 42, §1396g–1

The Public Health and Welfare, Source: USLM XML via OLRC

(a)The laws relating to medical child support, which a State is required to have in effect under section 1396a(a)(60) of this title, are as follows:

(1)A law that prohibits an insurer from denying enrollment of a child under the health coverage of the child’s parent on the ground that—

(A)the child was born out of wedlock,

(B)the child is not claimed as a dependent on the parent’s Federal income tax return, or

(C)the child does not reside with the parent or in the insurer’s service area.

(2)In any case in which a parent is required by a court or administrative order to provide health coverage for a child and the parent is eligible for family health coverage through an insurer, a law that requires such insurer—

(A)to permit such parent to enroll under such family coverage any such child who is otherwise eligible for such coverage (without regard to any enrollment season restrictions);

(B)if such a parent is enrolled but fails to make application to obtain coverage of such child, to enroll such child under such family coverage upon application by the child’s other parent or by the State agency administering the program under this subchapter or part D of subchapter IV; and

(C)not to disenroll (or eliminate coverage of) such a child unless the insurer is provided satisfactory written evidence that—

(i)such court or administrative order is no longer in effect, or

(ii)the child is or will be enrolled in comparable health coverage through another insurer which will take effect not later than the effective date of such disenrollment.

(3)In any case in which a parent is required by a court or administrative order to provide health coverage for a child and the parent is eligible for family health coverage through an employer doing business in the State, a law that requires such employer—

(A)to permit such parent to enroll under such family coverage any such child who is otherwise eligible for such coverage (without regard to any enrollment season restrictions);

(C)not to disenroll (or eliminate coverage of) any such child unless—

(i)the employer is provided satisfactory written evidence that—

(I)such court or administrative order is no longer in effect, or

(II)the child is or will be enrolled in comparable health coverage which will take effect not later than the effective date of such disenrollment, or

(ii)the employer has eliminated family health coverage for all of its employees; and

(D)to withhold from such employee’s compensation the employee’s share (if any) of premiums for health coverage (except that the amount so withheld may not exceed the maximum amount permitted to be withheld under section 1673(b) of title 15), and to pay such share of premiums to the insurer, except that the Secretary may provide by regulation for appropriate circumstances under which an employer may withhold less than such employee’s share of such premiums.

(4)A law that prohibits an insurer from imposing requirements on a State agency, which has been assigned the rights of an individual eligible for medical assistance under this subchapter and covered for health benefits from the insurer, that are different from requirements applicable to an agent or assignee of any other individual so covered.

(5)A law that requires an insurer, in any case in which a child has health coverage through the insurer of a noncustodial parent—

(A)to provide such information to the custodial parent as may be necessary for the child to obtain benefits through such coverage;

(B)to permit the custodial parent (or provider, with the custodial parent’s approval) to submit claims for covered services without the approval of the noncustodial parent; and

(C)to make payment on claims submitted in accordance with subparagraph (B) directly to such custodial parent, the provider, or the State agency.

(6)A law that permits the State agency under this subchapter to garnish the wages, salary, or other employment income of, and requires withholding amounts from State tax refunds to, any person who—

(A)is required by court or administrative order to provide coverage of the costs of health services to a child who is eligible for medical assistance under this subchapter,

(B)has received payment from a third party for the costs of such services to such child, but

(C)has not used such payments to reimburse, as appropriate, either the other parent or guardian of such child or the provider of such services,

(b)For purposes of this section, the term “insurer” includes a group health plan, as defined in section 1167(1) of title 29, a health maintenance organization, and an entity offering a service benefit plan.

Notes & Related Subsidiaries

Statutory Notes and Related Subsidiaries

Effective Date

Pub. L. 103–66, title XIII, § 13623(c), Aug. 10, 1993, 107 Stat. 635, provided that: “(1) Except as provided in paragraph (2), the

Amendments

made by this section [enacting this section and amending section 1396a of this title] apply to calendar quarters beginning on or after April 1, 1994, without regard to whether or not final

Regulations

to carry out such

Amendments

have been promulgated by such date. “(2) In the case of a State plan under title XIX of the Social Security Act [42 U.S.C. 1396 et seq.] which the Secretary of Health and Human Services determines requires State legislation in order for the plan to meet the additional requirements imposed by the

Amendments

made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet these additional requirements before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of enactment of this Act [Aug. 10, 1993]. For purposes of the preceding sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature.”

§1396g–1 Required Laws Relating to Medical Child Support

Summary

Title 42, §1396g–1

Notes & Related Subsidiaries

Statutory Notes and Related Subsidiaries

Effective Date

Amendments

Regulations

Amendments

Amendments

Citations & Metadata