In every Texas child support case, the court also issues medical and dental support orders that require one parent (usually the obligor) to provide the child’s health and dental insurance if it’s available at a reasonable cost, with cash payments substituted when it isn’t. “Reasonable cost” is set by statute: a premium up to nine percent of the obligor’s annual resources for health insurance, and up to 1.5 percent for dental. Out-of-pocket costs that insurance doesn’t cover are split separately between the parents. These obligations run until the child turns 18 or graduates high school, whichever is later.
The Nine Percent Cap on Health Insurance
Texas Family Code § 154.181 requires the court to address medical support in every proceeding involving child support: divorces, custody suits, paternity cases, and modifications. The court prefers private health insurance when a parent can obtain it at a reasonable cost, defined as a premium that does not exceed nine percent of the obligor’s annual resources for a single child.1State of Texas. Texas Family Code FAM 154.181
“Annual resources” here follows Section 154.062(b), which counts wages, self-employment income, retirement benefits, interest, dividends, and most other income before deductions. It’s the gross figure, not take-home pay.2State of Texas. Texas Family Code FAM 154.062 – Net Resources
Just as important: the nine percent applies to the cost of adding the child, not the total family premium. If your employer charges $400 a month for family coverage but only $150 of that is attributable to the child, the court measures the $150 against the threshold. The judge then decides which parent has access to the best available plan and usually orders that parent to carry it. If the custodial parent ends up providing coverage, the obligor is typically ordered to reimburse the premium as additional child support on top of the regular monthly amount.
The 1.5 Percent Cap on Dental Insurance
Dental coverage has its own statute and a lower ceiling. Under Texas Family Code § 154.1815, dental insurance is reasonable if the premium does not exceed 1.5 percent of the obligor’s annual resources. For a single child, the whole premium must fall within that limit. When several children are covered under the same dental support order, their combined premium must stay under the 1.5 percent cap.3State of Texas. Texas Family Code FAM 154.1815 – Dental Support Order
The court follows the same approach as with medical support: identify which parent has access to dental insurance, check the cost against the threshold, and order coverage accordingly. If no dental plan is currently in effect, both parents must tell the court whether either has access to affordable dental coverage.
Cash Medical Support When Insurance Isn’t Available
When neither parent can obtain private health insurance at or below the nine percent threshold, the court orders cash medical support under Texas Family Code § 154.182. Instead of an unaffordable premium, the obligor pays a monthly cash amount toward the child’s healthcare costs. That money often helps the custodial parent maintain the child’s Medicaid, CHIP, or other public coverage so the state isn’t left carrying costs a parent could contribute to.
Cash medical support is collected through wage withholding, the same channel used for regular child support. It’s meant to be a bridge: if the obligor’s employment changes and private insurance becomes affordable, either parent can petition to modify the order. If insurance never becomes reasonable, the cash obligation can stay in place for the duration of the child’s minority.
Splitting Unreimbursed Medical and Dental Costs
Premiums and cash support only pay for access to care. Deductibles, copayments, prescriptions, and other out-of-pocket expenses that insurance doesn’t reimburse are handled separately under Texas Family Code § 154.183. The statute directs the court to allocate these costs between the parents “according to their circumstances,” which gives the judge discretion to set a split that matches their financial positions.4State of Texas. Texas Family Code FAM 154.183
Many Texas orders divide these costs 50/50, but the statute does not require it. A parent earning significantly more may be assigned a larger share. The allocation covers health, dental, and vision expenses that insurance doesn’t reimburse, along with deductibles and copayments either parent pays for covered care.
In practice, the parent who pays a provider presents receipts to the other parent, who then reimburses their court-ordered share. The specific deadlines for submitting receipts and paying reimbursement come from the individual court order, not the statute, so read your order carefully. Failure to pay your share can lead to enforcement action, including contempt.
What You Must Disclose to the Court
Before the court can issue temporary or final orders, both parents have to disclose detailed information about existing or available coverage. Under § 154.181(b):
- If insurance is already in effect, disclose the carrier, policy number, which parent pays the premium, whether coverage runs through an employer, and the premium cost.
- If no insurance is in effect, disclose whether the child receives Medicaid or CHIP and whether either parent has access to private insurance at a reasonable cost.
Request a Summary of Benefits and Coverage from your HR department, and isolate the cost of adding the child specifically rather than the whole family premium; that’s the figure the court measures against the nine percent and 1.5 percent limits. The Texas Office of the Attorney General publishes medical support forms, including the National Medical Support Notice, on its website.5Texas Attorney General. Child Support Forms Missing or incomplete disclosures delay the case and can force additional hearings.
How the Order Reaches the Employer
Once the judge signs the order, implementation shifts to the obligor’s employer. The court or child support agency issues a National Medical Support Notice, a standardized federal form telling the employer that the employee is required to provide health coverage for the child.6Administration for Children and Families. National Medical Support Notice Forms and Instructions The employer forwards the plan-administrator portion to the health plan, the plan enrolls the child, premiums come out of the obligor’s wages, and the insurer sends plan information and ID cards to the custodial parent.
The National Medical Support Notice carries the force of a Qualified Medical Child Support Order under federal ERISA law (29 U.S.C. § 1169), which means employer-sponsored plans have to comply regardless of internal plan rules. The plan must enroll the child without waiting for open enrollment. If the plan requires the parent to be enrolled before adding a child, the administrator has to enroll both.7Office of the Law Revision Counsel. 29 USC 1169 – Additional Standards for Group Health Plans The plan cannot refuse enrollment because the child was born outside marriage, doesn’t live with the insured parent, isn’t claimed on the parent’s tax return, or lives outside the plan’s service area.8U.S. Department of Labor. Qualified Medical Child Support Orders
When Coverage Is Lost
Job changes and plan terminations can disrupt the child’s insurance. When the obligor’s employer-sponsored coverage ends, the employer must notify the Texas Office of the Attorney General within 15 days by completing a Health Insurance Status Change Form.9Texas Attorney General. Medical Support Frequently Asked Questions That triggers the process of finding replacement coverage or converting the order to cash medical support.
Don’t wait it out. If affordable insurance becomes available through a new employer or the marketplace, either parent can petition to modify the order. Letting coverage lapse without notifying the court or the other parent creates enforcement exposure and leaves the child uninsured, which is what these orders exist to prevent.
Enforcement When a Parent Doesn’t Comply
Medical and dental support are enforceable through the same tools as regular child support. If a parent fails to maintain required coverage, refuses to pay their share of unreimbursed expenses, or stops making cash medical support payments, the other parent can file a motion for contempt. To succeed, the moving party has to show a valid order existed, the other parent knew about it, had the ability to comply, and willfully failed to do so.
Texas courts can impose:
- Jail time. Civil contempt uses confinement to force compliance; the parent can purge it by complying. Criminal contempt is a fixed sentence for past willful disobedience.
- Fines and attorney’s fees. The noncompliant parent may be ordered to pay the other parent’s legal costs.
- Wage garnishment for past-due amounts.
- Suspension of driver’s, professional, and recreational licenses.
Courts commonly try civil contempt first, reserving criminal contempt for repeated or egregious violations.
Modifying a Medical or Dental Support Order
These orders aren’t fixed forever. Under Texas Family Code § 156.401, either parent can petition to modify if the circumstances of the child or a parent have materially and substantially changed since the order was issued. Common triggers: a job change that makes insurance newly available or newly unaffordable, a significant income shift, or changes in the child’s medical needs.10State of Texas. Texas Family Code FAM 156.401
A separate automatic review path also exists: if three years have passed since the order was rendered or last modified and the monthly child support amount would differ by at least 20 percent or $100 under current guidelines, the court can modify without a showing of material change. In Title IV-D cases handled by the Attorney General, the court can add medical or dental support to an order that lacks it at any time, without proving changed circumstances.
When the Obligation Ends
Medical and dental support end under the same conditions as regular child support. Under Texas Family Code § 154.001, the obligation ends at the earliest of:
- Age 18 or high school graduation, whichever is later. A child who turns 18 in January but graduates in May stays covered through graduation.
- Marriage or emancipation. If the child marries or a court removes the disabilities of minority, the obligation ends regardless of age.
- Death of the child.
- Indefinite support for a disabled child. If a disability prevents self-support, the court can order medical and dental support to continue past the age of majority.11State of Texas. Texas Family Code FAM 154.001
Termination isn’t always automatic. If a qualifying event has occurred, file the appropriate paperwork with the court or the Attorney General’s office to formally end the obligation. Ignoring an order because you think it should have ended can still expose you to enforcement until the order is officially modified or terminated.