Texas child support orders cover more than basic monthly payments. Under Texas Family Code § 154.008, courts must also order medical and dental support. These obligations are required by law and are separate from standard monthly child support under Texas Family Code § 154.064. These orders can include insurance coverage, premium reimbursement, cash medical support, and paying for medical bills that insurance does not cover.
Medical support generally covers health insurance and medical costs. Dental support covers dental insurance and dental expenses. Cash medical support is an additional child support payment the court orders when health insurance is not available for the child through the statutory insurance options. These distinctions help clarify what each parent must provide or pay under a Texas child support order.
What Is the Difference Between Medical Support, Dental Support, and Cash Medical Support?
These are three separate obligations under Texas Family Code Chapter 154. Medical support is the duty to provide for a child’s health care, usually by carrying the child on a health insurance plan. Dental support is a separate duty covering dental insurance and dental expenses. Cash medical support is money the parent who pays child support pays when no qualifying health insurance is available at a reasonable cost — it takes the place of coverage rather than adding to it.
The reasonable-cost limits
Health insurance is generally considered available at a reasonable cost when the cost of covering the child does not exceed 9% of the annual resources of the parent who pays child support. The limit for dental insurance is 1.5%. Both percentages are measured against annual resources as defined by § 154.062(b), which is not the same as take-home pay. When the parent who pays support is responsible for covering more than one child, the limit applies to the total cost of covering all of them, not to each child separately.
Ordering a parent to carry coverage does not always mean that parent bears its cost. When the parent who receives child support is the parent ordered to provide the insurance, the court orders the support-paying parent to pay the other parent an amount equal to the actual cost of that coverage.
What happens when the premium costs too much?
The statute does not let the court pick freely among the available options. It sets them in a fixed order, and the court works down that order until it reaches one that qualifies. An option that fails the reasonable-cost test — a plan whose premium for the child exceeds the applicable percentage — does not qualify, so the court passes over it and considers the next one. A plan that costs too much is not ordered anyway with the excess split between the parents. It simply drops out.
The order, set out in Texas Family Code § 154.182(b), is:
- Coverage through a parent’s employment or organization. If health insurance is available for the child through a parent’s job, union, or trade association at reasonable cost, the court must order that parent to enroll the child. This step is mandatory, so if a qualifying plan exists here, the analysis ends and the court never reaches the later options.
- Coverage from another source. If no qualifying plan is available at step one, the court may order a parent to provide coverage from another source at reasonable cost. This step is discretionary, so the court can order coverage here but is not required to.
- Cash medical support. If no qualifying coverage is available at either earlier step, the court must order cash medical support. This is the last step, reached only after the coverage options above have been ruled out.
Medicaid and the Children’s Health Insurance Program, known as CHIP, work differently. Both are government medical assistance programs administered by the state. Medicaid covers children in low-income households, and CHIP covers children whose families earn too much to qualify for Medicaid but cannot readily afford private coverage. A court cannot order a parent to provide either one, because eligibility is determined by the state rather than by the court. What the court can do, when neither parent has access to private health insurance at a reasonable cost, is order the appropriate parent to apply immediately for the child’s participation in such a program.
How cash medical support works
When no parent has health insurance available for the child at a reasonable cost, the court orders money. The amount is not based on what the child’s medical care actually costs. It is a set amount stated in the order, capped at 9% of the annual resources of the parent who pays child support, and it is owed in full whether or not the child sees a doctor that month. It does not rise in a month that brings a hospital stay or fall in a month with no appointments, and it is not a reimbursement of bills the other parent has already paid. Unreimbursed and uninsured medical expenses are handled separately. See section below.
Cash medical support is paid by the parent who pays child support to the other parent and is in addition to the regular child support obligation under § 154.183 — not carved out of it — so a parent ordered to pay both pays both. It is enforceable by the same means as child support.
Because the obligation depends on what coverage is available, a change in what an employer offers can be grounds to revisit the order.
Dental support
Dental support became a separate statutory obligation on September 1, 2018, when the child support statutes were amended to address dental insurance and dental expenses alongside medical support. It has its own provision, § 154.1825, which sets a priority order built the same way as the one above: employment or organization coverage first, then coverage from another source.
Two things differ. The reasonable-cost limit is 1.5% rather than 9%. And there is no third step — Texas law does not create a parallel cash dental support obligation, so when private dental insurance is not available at a reasonable cost, there is no dental equivalent of the money-instead-of-coverage order.
A parent’s employer might offer health coverage for the child within the 9% limit while its dental plan exceeds the 1.5% limit. In that situation the court can order the qualifying health coverage and address dental separately.
Which Parent Has to Provide Medical and Dental Insurance?
Either parent may be ordered to provide medical or dental insurance. The parent who pays child support is not automatically the parent who must carry the policy.
The court considers the cost, accessibility, and quality of the coverage available to each parent. Cost is the reasonable-cost limit described above. Accessibility means the plan provides care within a reasonable traveling distance and time from the child’s primary residence, so a plan can meet the cost limit and still not be the plan ordered if its network does not reach where the child lives. Applying those factors to the priority order described above, the parent ordered to provide coverage is the parent who has qualifying coverage available. A parent with no qualifying plan available cannot be ordered to produce one.
When the parent who receives child support is the parent ordered to provide coverage, the court orders the parent who pays child support to pay the other parent an amount equal to the actual cost of that coverage, as additional child support. This applies to health insurance and, under § 154.1825(d), to dental insurance as well.
The signed order or divorce decree controls. It should identify who must provide coverage, who pays or reimburses premiums, whether cash medical support applies, how uninsured expenses are divided, and what reimbursement procedures apply. An informal agreement between the parents does not change those court-ordered duties.
How Are Uninsured Medical, Dental, and Orthodontic Expenses Divided?
Texas law does not require a universal 50/50 split of uninsured health care expenses. Under Texas Family Code § 154.183, the court must allocate reasonable and necessary health care expenses not reimbursed by insurance or otherwise covered by cash medical support between the parents according to their circumstances.
These expenses can include deductibles, copayments, unreimbursed vision and dental expenses, and other reasonable and necessary health care costs. Orthodontic treatment may fall within dental expenses, but whether a particular orthodontic charge must be reimbursed depends on the terms of the support order and whether the expense satisfies the applicable requirements.
For example, suppose covered dental treatment costs $1,200 and insurance pays $700. The remaining $500 is uninsured. If the court order allocates those qualifying expenses equally, each parent would be responsible for $250. If the order uses a different allocation, that allocation controls.
The reimbursement procedure comes from the order. Many Texas orders use two 30-day deadlines: the parent who took the child for the care has 30 days from receiving the paperwork to send the other parent the bills and explanations of benefits showing what insurance did not cover, and the other parent has 30 days from receiving those documents to pay that share.
The second clock does not start until the documents arrive, so delaying the paperwork delays the other parent’s deadline. Not every order uses these periods, and parents should follow the deadlines in their own order rather than assume that a 30-day period or a 50/50 division applies in every Texas case.
What Happens If a Parent Does Not Provide Coverage or Pay Their Share?
Enforcement addresses what has already gone unprovided or unpaid under the existing order. Changing the order going forward is a separate process, covered in the next section.
Medical and dental support obligations are child support obligations and can be enforced through the procedures available for enforcing child support, including income withholding where applicable (§ 154.183). Texas Family Code § 154.188 adds a specific consequence: a parent ordered to provide health or dental insurance, or to pay additional child support for the cost of that insurance, who fails to do so can be held liable for the child’s necessary medical and dental expenses and for the insurance premiums or contributions paid on the child’s behalf. So if an order requires a parent to reimburse 50% of qualifying uninsured dental expenses and that parent does not pay properly documented amounts, the other parent may seek enforcement of the existing order.
A parent should not assume that losing insurance suspends the existing obligation. A parent ordered to provide health or dental insurance generally must notify the other parent, and any child support agency enforcing the obligation, no later than 15 days after the coverage terminates or lapses (§ 154.189). Notice is generally required within 15 days if replacement coverage later becomes available.
Can Medical or Dental Support Be Modified?
Yes. Medical and dental support can be modified when the requirements under Texas Family Code § 156.401 are met.
A court may modify medical or dental support after a material and substantial change in the circumstances of the child or another person affected by the order. A change in employment, loss of insurance, or a significant change in available coverage may be relevant, depending on the circumstances.
Another general basis for modifying child support may apply when at least three years have passed since the order was entered or last modified and the current support amount differs from the guideline amount by either 20% or $100. This three-year route is not available when the parents agreed to a support amount that differs from the guideline amount. In that situation, the order can be modified only by showing a material and substantial change in circumstances.
A modification generally applies only to support obligations that accrue after the other parent is served with citation in the modification suit, or files an appearance in it, whichever comes first (§ 156.401(b)). Filing does not reach backward. Amounts that came due before that point remain owed under the existing order.
An informal agreement between parents does not itself modify a court order. Until the order is changed through the applicable legal process, the existing order generally remains the enforceable directive.
Talk With a Texas Family Law Attorney About Medical and Dental Support
Medical support, dental support, cash medical support, and unreimbursed health care expenses can create disputes when an order is outdated, unclear, or no longer reflects the insurance available to the parents. The appropriate legal process may involve a motion to enforce an existing order or a suit to modify the order, depending on the issue.
If you have questions about a Texas child support order, medical or dental coverage, unpaid health care expenses, or a possible modification, contact Bailey & Galyen to discuss the order and the legal options that may apply.
Frequently Asked Questions
1. Is dental support separate from regular child support in Texas?
Yes. Texas law treats dental support as an additional child support obligation. Texas Family Code § 154.064 states that the child support guidelines assume the parent paying support will provide medical support and dental support in addition to guideline child support.
2. Are braces considered a dental expense in Texas child support cases?
Orthodontic treatment such as braces can be treated as a dental expense, but responsibility for a particular bill depends on the support order and the circumstances of the expense. Texas Family Code § 154.183 requires the court to allocate reasonable and necessary unreimbursed health care expenses, including dental expenses, between the parents according to their circumstances. Parents should review the decree for any notice, documentation, consent, or reimbursement requirements that apply to orthodontic treatment.
3. What if the parent ordered to provide insurance loses that coverage?
The existing support order does not automatically disappear when coverage is lost. A parent paying child support who is ordered to provide health or dental insurance must give notice of the termination or lapse to the other parent and any enforcing child support agency no later than 15 days after the loss of coverage under Texas Family Code § 154.189. If replacement coverage becomes available, the statute requires notice within 15 days after it becomes available.
Depending on the existing order and the insurance options then available, a modification may be needed to change which parent provides coverage or how medical support is paid.
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