S.F. _____ H.F. _____ Section 1. Section 252C.1, subsection 6, Code 2018, is 1 amended to read as follows: 2 6. “Medical support” means either the provision of 3 coverage under a health benefit plan, including a group or 4 employment-related or an individual health benefit plan, or 5 a health benefit plan provided pursuant to chapter 514E , to 6 meet the medical needs of a dependent and the cost of any 7 premium required by a health benefit plan, or the payment to 8 the obligee of a monetary amount in lieu of providing coverage 9 under a health benefit plan, either of which is an obligation 10 separate from any monetary amount of child support ordered 11 to be paid. Medical support which consists of payment of 12 a monetary amount in lieu of a health benefit plan is also 13 an obligation separate from any monetary amount a parent is 14 ordered to pay for uncovered medical expenses pursuant to the 15 guidelines established pursuant to section 598.21B medical 16 support as defined in section 252E.1 . 17 Sec. 2. Section 252E.1, Code 2018, is amended to read as 18 follows: 19 252E.1 Definitions. 20 As used in this chapter , unless the context otherwise 21 requires: 22 1. “Accessible” means any of the following, unless otherwise 23 provided in the support order: 24 a. The health benefit plan does not have service area 25 limitations or provides an option not subject to service area 26 limitations. 27 b. The health benefit plan has service area limitations and 28 the dependent lives within thirty miles or thirty minutes of a 29 network primary care provider. 30 2. “Basic coverage” means health care coverage provided 31 under a health benefit plan that at a minimum provides coverage 32 for emergency care, inpatient and outpatient hospital care, 33 physician services whether provided within or outside a 34 hospital setting, and laboratory and x-ray services. 35 -1- LSB 5326XD (7) 87 pf/rh 1/ 13

S.F. _____ H.F. _____ 3. “Cash medical support” means a monetary amount that 1 a parent is ordered to pay to the obligee in lieu of that 2 parent providing health care coverage, which amount is five 3 percent of the gross income of the parent ordered to pay the 4 monetary amount or, if the child support guidelines established 5 pursuant to section 598.21B specifically provide an alternative 6 income-based numeric standard for determining the amount, 7 the amount determined by the standard specified by the child 8 support guidelines. “Cash medical support” is an obligation 9 separate from any monetary amount a parent is ordered to pay 10 for uncovered medical expenses pursuant to the guidelines 11 established pursuant to section 598.21B. 12 3. 4. “Child” means a person for whom child or medical 13 support may be ordered pursuant to chapter 234 , 239B , 252A , 14 252C , 252F , 252H , 252K , 598 , 600B , or any other chapter of the 15 Code or pursuant to a comparable statute of another state or 16 foreign country. 17 4. 5. “Department” means the department of human services, 18 which includes but is not limited to the child support recovery 19 unit, or any comparable support enforcement agency of another 20 state. 21 5. 6. “Dependent” means a child, or an obligee for whom a 22 court may order health care coverage by a health benefit plan 23 pursuant to section 252E.3 . 24 6. 7. “Enroll” means to be eligible for and covered by a 25 health benefit plan. 26 7. 8. “Health benefit plan” means any policy or contract 27 of insurance, indemnity, subscription or membership issued by 28 an insurer, health service corporation, health maintenance 29 organization, or any similar corporation, organization any 30 public coverage , or a any self-insured employee benefit plan, 31 for the purpose of covering medical expenses. These expenses 32 may include but are not limited to hospital, surgical, major 33 medical insurance, dental, optical, prescription drugs, office 34 visits, or any combination of these or any other comparable 35 -2- LSB 5326XD (7) 87 pf/rh 2/ 13

S.F. _____ H.F. _____ health care expenses. 1 9. “Health care coverage” or “coverage” means providing and 2 paying for the medical needs of a dependent through a health 3 benefit plan. 4 8. 10. “Insurer” means any entity which provides a health 5 benefit plan , but does not include an entity that provides 6 public coverage . 7 9. 11. “Medical support” means either the provision of a 8 health benefit plan, including a group or employment-related 9 or an individual health benefit plan, or a health benefit plan 10 provided pursuant to chapter 514E , to meet the medical needs 11 of a dependent and the cost of any premium required by a health 12 benefit plan, care coverage or the payment to the obligee of 13 a monetary amount in lieu of a health benefit plan, either 14 of which is an obligation separate from any monetary amount 15 of child cash medical support ordered to be paid . Medical 16 support “Medical support” is not alimony. Medical support which 17 consists of payment of a monetary amount in lieu of a health 18 benefit plan is also an obligation separate from any monetary 19 amount a parent is ordered to pay for uncovered medical 20 expenses pursuant to the guidelines established pursuant to 21 section 598.21B . 22 10. 12. “National medical support notice” means a notice 23 as prescribed under 42 U.S.C. §666(a)(19) or a substantially 24 similar notice, that is issued and forwarded by the department 25 in accordance with section 252E.4 to enforce medical support 26 the health care coverage provisions of a support order. The 27 national medical support notice is not applicable to a provider 28 of public coverage. 29 11. 13. “Obligee” means a parent or another natural person 30 legally entitled to receive a support payment on behalf of a 31 child. 32 12. 14. “Obligor” means a parent or another natural person 33 legally responsible for the support of a dependent. 34 13. 15. “Order” means a support order entered pursuant to 35 -3- LSB 5326XD (7) 87 pf/rh 3/ 13

S.F. _____ H.F. _____ chapter 234 , 252A , 252C , 252F , 252H , 252K , 598 , 600B , or any 1 other support chapter, or pursuant to a comparable statute of 2 another state or foreign country, or an ex parte order entered 3 pursuant to section 252E.4 . “Order” also includes a notice of 4 such an order issued by the department. 5 14. 16. “Plan administrator” means the employer or sponsor 6 that offers the health benefit plan or the person to whom the 7 duty of plan administrator is delegated by the employer or 8 sponsor offering the health benefit plan, by written agreement 9 of the parties. “Plan administrator” does not include a 10 provider of public coverage. 11 15. 17. “Primary care provider” means a physician who 12 provides primary care who is a family or general practitioner, 13 a pediatrician, an internist, an obstetrician, or a 14 gynecologist. 15 18. “Public coverage” means health care benefits provided by 16 any form of federal or state medical assistance, including but 17 not limited to benefits provided under chapter 249A or 514I, 18 or under comparable laws of another state, foreign country, or 19 Indian nation or tribe. 20 19. “Unit” or “child support recovery unit” means unit as 21 defined in section 252B.1. 22 Sec. 3. Section 252E.1A, Code 2018, is amended to read as 23 follows: 24 252E.1A Establishing and modifying orders for medical 25 support. 26 1. This section shall apply to all initial or modified 27 orders for support entered under chapter 234 , 252A , 252C , 252F , 28 252H , 598 , 600B , or any other applicable chapter. If an action 29 to establish or modify an order for support is initiated by the 30 child support recovery unit, section 252E.1B shall also apply. 31 1. 2. An order or judgment that provides for temporary or 32 permanent support for a child shall include a provision for 33 medical support for the child as provided in this section . 34 2. 3. The court shall order as medical support for the 35 -4- LSB 5326XD (7) 87 pf/rh 4/ 13

S.F. _____ H.F. _____ child health care coverage if a health benefit plan if other 1 than public coverage is available to either parent at the time 2 the order is entered or modified. A health benefit plan is 3 available if the plan is accessible and the cost of the plan is 4 reasonable. 5 a. The cost of a health benefit plan is considered 6 reasonable, and such amount shall be stated in the order, if 7 one of the following applies: 8 (1) The premium cost for a child to the parent ordered 9 to provide the plan coverage does not exceed five percent of 10 that parent’s gross income or the child support guidelines 11 established pursuant to section 598.21B specifically provide an 12 alternative income-based numeric standard for determining the 13 reasonable cost of the premium, in which case the reasonable 14 cost of the premium as determined by the standard specified by 15 the child support guidelines shall apply. 16 (2) The premium cost for a child exceeds the amount 17 specified in subparagraph (1) and that parent consents or does 18 not object to entry of that order. 19 b. For purposes of this section , “gross income” has the same 20 meaning as gross income for calculation of support under the 21 guidelines established under section 598.21B . 22 c. For purposes of this section , “the premium cost for 23 a child to the parent” ordered to provide the plan coverage 24 means the amount of the premium cost for family coverage to 25 the parent which is in excess of the premium cost for single 26 coverage, regardless of the number of individuals covered under 27 the plan. However, this paragraph shall not be interpreted to 28 reduce the amount of the health insurance premium deduction 29 a parent may be entitled to when calculating the amount of a 30 child support obligation under Iowa court rule 9.5 of the child 31 support guidelines. 32 d. For purposes of this section, “family coverage” means 33 coverage that covers multiple individuals and covers or could 34 cover the child or children subject to the child support order. 35 -5- LSB 5326XD (7) 87 pf/rh 5/ 13

S.F. _____ H.F. _____ 3. 4. If a health benefit plan other than public coverage 1 is not available to either parent at the time of the entry 2 of the order, and the custodial parent does not have public 3 coverage for the child, the court shall order a reasonable 4 monetary cash medical support in an amount in lieu of a health 5 benefit plan, which amount shall be stated in the order. For 6 purposes of this subsection , a reasonable amount means five 7 percent of the gross income of the parent ordered to provide 8 the monetary amount for medical support or, if the child 9 support guidelines established pursuant to section 598.21B 10 specifically provide an alternative income-based numeric 11 standard for determining the reasonable amount, a reasonable 12 amount means the amount as determined by the standard specified 13 by the child support guidelines. This subsection shall not 14 apply in any of the following circumstances: 15 a. If the parent’s monthly support obligation established 16 pursuant to the child support guidelines prescribed by the 17 supreme court pursuant to section 598.21B is the minimum 18 obligation amount. If this paragraph applies, the court shall 19 order the parent to provide a health benefit plan care coverage 20 when a plan becomes available for which there is no premium 21 cost for a child to the parent. 22 b. If subsection 7 , paragraph “d” , “e” , or “f” applies the 23 noncustodial parent does not have income which may be subject 24 to income withholding for collection of cash medical support at 25 the time of the entry of the order. If this paragraph applies, 26 the court shall order the noncustodial parent to provide health 27 care coverage when a health benefit plan becomes available at 28 a reasonable cost, and the order shall specify the amount of 29 the reasonable cost as specified in subsection 3, paragraph “a” , 30 subparagraph (1) . 31 c. If the noncustodial parent is receiving assistance or 32 is residing with any child receiving assistance as provided 33 in section 252E.2A, subsection 1, paragraph “c” , subparagraph 34 (3) or (4). If this paragraph applies, the court shall order 35 -6- LSB 5326XD (7) 87 pf/rh 6/ 13

S.F. _____ H.F. _____ the noncustodial parent to provide health care coverage when 1 a health benefit plan becomes available for which there is no 2 premium cost for a child to the parent. 3 4. 5. If a health benefit plan other than public coverage 4 is not available to either parent at the time of the entry of 5 the order, and the custodial parent has public coverage for the 6 child, the court orders shall order the custodial parent to 7 provide a health benefit plan under subsection 2 care coverage , 8 and the court may also shall order the noncustodial parent to 9 provide a reasonable monetary pay cash medical support, which 10 amount in lieu of a health benefit plan shall be stated in the 11 order, unless an exception under subsection 4 applies . For 12 purposes of this subsection , a reasonable monetary amount means 13 an amount not to exceed the lesser of a reasonable amount as 14 described in subsection 3 , or the premium cost of coverage for 15 the child to the custodial parent as described in subsection 16 2 , paragraph “c” . 17 5. 6. Notwithstanding the requirements of this section , the 18 court may order provisions in the alternative to those provided 19 in this section to address the health care needs of the child 20 if the court determines that extreme circumstances so require 21 and documents the court’s written findings in the order. 22 6. 7. An order, decree, or judgment entered before July 1, 23 2009 October 1, 2018 , that provides for the support of a child 24 may be modified in accordance with this section . 25 7. If the child support recovery unit is providing services 26 under chapter 252B and initiating an action to establish or 27 modify support, all of the following shall also apply: 28 a. If a health benefit plan is available as described in 29 subsection 2 to the noncustodial parent, the unit shall seek an 30 order for the noncustodial parent to provide the plan. 31 b. If a health benefit plan is available as described 32 in subsection 2 to the custodial parent and not to the 33 noncustodial parent, the unit shall seek an order for the 34 custodial parent to provide the plan. 35 -7- LSB 5326XD (7) 87 pf/rh 7/ 13

S.F. _____ H.F. _____ c. If a health benefit plan is available as described in 1 subsection 2 to each parent, and if there is an order for joint 2 physical care, the unit shall seek an order for the parent 3 currently ordered to provide a health benefit plan to provide 4 the plan. If there is no current order for a health benefit 5 plan for the child, the unit shall seek an order for the parent 6 who is currently providing a health benefit plan to provide the 7 plan. 8 d. If a health benefit plan is not available, and the 9 noncustodial parent does not have income which may be subject 10 to income withholding for collection of a reasonable monetary 11 amount in lieu of a health benefit plan at the time of the 12 entry of the order, the unit shall seek an order that the 13 noncustodial parent provide a health benefit plan when a plan 14 becomes available at reasonable cost, and the order shall 15 specify the amount of reasonable cost as defined in subsection 16 2 . 17 e. If a health benefit plan is not available, and the 18 noncustodial parent is receiving assistance or is residing with 19 any child receiving assistance as provided in section 252E.2A, 20 subsection 1 , paragraph “c” , subparagraph (3) or (4), the unit 21 shall seek an order that the noncustodial parent shall provide 22 a health benefit plan when a plan becomes available for which 23 there is no premium cost for a child to the parent. 24 f. This section shall not apply to chapter 252H, subchapter 25 IV . 26 Sec. 4. NEW SECTION . 252E.1B Establishing and modifying 27 orders for medical support —— actions initiated by child support 28 recovery unit. 29 1. If the child support recovery unit is initiating an 30 action to establish or modify support, this section shall apply 31 in addition to the provisions of section 252E.1A. 32 2. The unit shall apply the following order of priority when 33 the unit enters or seeks an order for medical support: 34 a. If the custodial parent is currently providing coverage 35 -8- LSB 5326XD (7) 87 pf/rh 8/ 13

S.F. _____ H.F. _____ for the child under a health benefit plan other than public 1 coverage, and the plan is available as described in section 2 252E.1A, subsection 3, the unit shall enter or seek an order 3 for the custodial parent to provide coverage. 4 b. If the noncustodial parent is currently providing 5 coverage for the child under a health benefit plan other than 6 public coverage, and the plan is available as described in 7 section 252E.1A, subsection 3, the unit shall enter or seek an 8 order for the noncustodial parent to provide coverage. 9 c. If a health benefit plan other than public coverage is 10 available as described in section 252E.1A, subsection 3, to the 11 custodial parent, the unit shall enter or seek an order for the 12 custodial parent to provide coverage. 13 d. If a health benefit plan other than public coverage is 14 available as described in section 252E.1A, subsection 3, to the 15 noncustodial parent, the unit shall enter or seek an order for 16 the noncustodial parent to provide coverage. 17 e. If a health benefit plan other than public coverage is 18 not available to either parent, and the custodial parent has 19 public coverage for the child, the unit shall enter or seek an 20 order for the custodial parent to provide health care coverage 21 and shall enter or seek an order for the noncustodial parent to 22 pay cash medical support. However, if any of the circumstances 23 described in section 252E.1A, subsection 4, paragraph “a” , 24 “b” , or “c” is met, the unit shall enter or seek an order as 25 specified by the applicable paragraph. 26 3. Notwithstanding subsection 2, if there is an order for 27 joint physical care for the child and the parties subject to 28 the support order, the unit shall apply the following order of 29 priority when the unit enters or seeks an order for medical 30 support: 31 a. If only one parent is currently providing coverage 32 for the child under a health benefit plan other than public 33 coverage, and the plan is available as described in section 34 252E.1A, subsection 3, the unit shall enter or seek an order 35 -9- LSB 5326XD (7) 87 pf/rh 9/ 13

S.F. _____ H.F. _____ for that parent to provide coverage. 1 b. If both parents are currently providing coverage for the 2 child under a health benefit plan other than public coverage, 3 and both plans are available as described in section 252E.1A, 4 subsection 3, the unit shall enter or seek an order for both 5 parents to provide coverage. 6 c. If neither parent is currently providing coverage 7 for the child under a health benefit plan other than public 8 coverage, and a health benefit plan other than public coverage 9 is available as described in section 252E.1A, subsection 3, 10 to one parent, the unit shall enter or seek an order for that 11 parent to provide coverage. 12 d. If neither parent is currently providing coverage 13 for the child under a health benefit plan other than public 14 coverage, and a health benefit plan other than public coverage 15 is available as described in section 252E.1A, subsection 3, to 16 both parents, the unit shall enter or seek an order for both 17 parents to provide coverage. 18 e. If a health benefit plan other than public coverage 19 is not available to either parent and one parent has public 20 coverage for the child, the unit shall enter or seek an order 21 for that parent to provide health care coverage. 22 4. The child support recovery unit or the court shall not 23 order any modification to an existing medical support order 24 in a proceeding conducted solely pursuant to chapter 252H, 25 subchapter IV. 26 Sec. 5. Section 252E.2, subsection 1, Code 2018, is amended 27 to read as follows: 28 1. An order requiring the provision of coverage under a 29 health benefit plan other than public coverage is authorization 30 for enrollment of the dependent if the dependent is otherwise 31 eligible to be enrolled. The dependent’s eligibility and 32 enrollment for coverage under such a plan shall be governed by 33 all applicable terms and conditions, including, but not limited 34 to, eligibility and insurability standards. The dependent, if 35 -10- LSB 5326XD (7) 87 pf/rh 10/ 13

S.F. _____ H.F. _____ eligible, shall be provided the same coverage as the obligor. 1 Sec. 6. Section 252E.3, Code 2018, is amended to read as 2 follows: 3 252E.3 Health benefit care coverage of obligee. 4 For cases for which services are being provided pursuant 5 to chapter 252B , the order may require an obligor providing a 6 health benefit plan care coverage for a child to also provide a 7 health benefit plan care coverage for the benefit of an obligee 8 if the obligee is eligible for enrollment under the plan in 9 which the child or the obligor is enrolled, and if the plan 10 coverage for the obligee is available at no additional cost. 11 Sec. 7. Section 252E.4, subsection 1, Code 2018, is amended 12 to read as follows: 13 1. When a support order requires an obligor to provide 14 coverage under a health benefit plan other than public 15 coverage , the district court or the department may enter an 16 ex parte order directing an employer to take all actions 17 necessary to enroll an obligor’s dependent for coverage under 18 a health benefit plan or may include the provisions in an ex 19 parte income withholding order or notice of income withholding 20 pursuant to chapter 252D . The child support recovery unit, 21 where appropriate, shall issue a national medical support 22 notice to an employer within two business days after the 23 date information regarding a newly hired employee is entered 24 into the centralized employee registry and matched with a 25 noncustodial parent in the case being enforced by the unit, or 26 upon receipt of other employment information for such parent. 27 The department may amend the information in the ex parte order 28 or may amend or terminate the national medical support notice 29 regarding health insurance provisions if necessary to comply 30 with health insurance requirements including but not limited to 31 the provisions of section 252E.2, subsection 2 , or to correct 32 a mistake of fact. 33 Sec. 8. Section 252E.16, subsection 1, Code 2018, is amended 34 to read as follows: 35 -11- LSB 5326XD (7) 87 pf/rh 11/ 13

S.F. _____ H.F. _____ 1. The Unless otherwise specified, the provisions of this 1 chapter take effect July 1, 1990, for all support orders 2 entered pursuant to chapter 234 , 252A , 252C , 598 , or 600B . 3 Sec. 9. ADMINISTRATIVE RULES —— TRANSITION. Until such 4 time as the department of human services adopts rules pursuant 5 to chapter 17A necessary to administer this Act, all of the 6 following shall apply: 7 1. The child support recovery unit may initiate proceedings 8 to establish and modify support orders in accordance with 9 chapter 252E, as amended in this Act. 10 2. The child support recovery unit may, to the extent 11 appropriate, apply and utilize procedures, rules, and forms 12 substantially similar to those applicable and utilized pursuant 13 to section 252E.1B, as enacted in this Act, for proceedings 14 initiated in accordance with section 252E.1A. 15 Sec. 10. EFFECTIVE DATE. This Act takes effect October 1, 16 2018. 17 EXPLANATION 18 The inclusion of this explanation does not constitute agreement with 19 the explanation’s substance by the members of the general assembly. 20 This bill amends provisions relating to medical support 21 for a child, based on the final rule adopted by the centers 22 for Medicare and Medicaid services and the administration 23 for children and families of the United States department of 24 health and human services on December 20, 2016, pursuant to 25 Executive Order 13563 of January 18, 2011. Under 45 C.F.R. 26 subtitle B, chapter III, section 303.31, specifically, states 27 are provided with flexibility to permit parents to meet their 28 medical support obligations by providing health care coverage 29 or payment for medical expenses that are reasonable in cost and 30 best meet the health care needs of the child, and clarifies 31 that health care coverage includes public and private coverage. 32 The bill provides definitions including “cash medical 33 support”, “health care coverage”, and “public coverage”, and 34 includes public coverage in the definition of a “health benefit 35 -12- LSB 5326XD (7) 87 pf/rh 12/ 13

S.F. _____ H.F. _____ plan”. 1 The bill provides for the provision of medical support 2 either by providing and paying for the medical needs of a 3 dependent through a health benefit plan, including public 4 coverage, or the payment of cash medical support. The bill 5 provides the conditions for determining whether medical support 6 is to be provided through a health benefit plan other than 7 public coverage or through public coverage and whether the 8 custodial or noncustodial parent is required to provide health 9 care coverage. 10 The bill also provides the process and order of priority to 11 be followed when the child support recovery unit (CSRU) enters 12 or seeks an order for medical support. 13 The bill directs the department of human services to adopt 14 rules pursuant to Code chapter 17A as necessary to administer 15 the bill, but provides that until such time as rules are 16 adopted the CSRU may initiate proceedings to establish and 17 modify support orders in accordance with Code chapter 252E, 18 as amended in the bill, and may, to the extent appropriate, 19 apply and utilize procedures, rules, and forms substantially 20 similar to those applicable and utilized pursuant to Code 21 section 252E.1B for proceedings initiated in accordance with 22 Code section 252E.1A, as enacted in the bill. 23 The bill takes effect October 1, 2018. 24 -13- LSB 5326XD (7) 87 pf/rh 13/ 13