Texas law requires every child support order to address health insurance and medical costs. This page explains how the rules work and what happens when circumstances change.
Under Texas Family Code §154.181, every child support order must include a provision for the health care of the child. This is not optional — courts are required to address medical support regardless of whether either party requests it. Medical support and base child support are technically separate obligations, though they appear in the same order.
Texas uses two mechanisms to satisfy the medical support requirement:
1. Health Insurance Coverage — If a parent has access to health insurance for the child at a reasonable cost, the court orders that parent to provide coverage.
2. Cash Medical Support — If health insurance is not available at a reasonable cost, the court instead orders an additional monthly cash payment (called "cash medical support") to help cover the child's healthcare expenses.
When health insurance is available to either parent through an employer or union at a reasonable cost, the court orders that parent to provide health insurance coverage for the child. Under TFC §154.182, "reasonable cost" means the cost does not exceed 9% of the obligor's annual resources (including the cost of the child's coverage only, not the entire family plan).
The parent ordered to provide insurance must:
The cost of the child's portion of the health insurance premium is factored into the base child support calculation — it is one of the deductions from gross income when calculating net resources. If the obligee (receiving parent) provides insurance, the obligor may be ordered to reimburse a portion of the premium.
If neither parent has access to health insurance at a reasonable cost — for example, if both are self-employed or if employer-sponsored insurance is not available — the court orders cash medical support under TFC §154.182(b).
Cash medical support is an additional monthly payment on top of base child support. The amount is determined by the court based on what is fair and reasonable given the parties' resources. It is intended to be used for the child's healthcare expenses.
Cash medical support is paid monthly like base child support and is enforceable in the same way — including through wage withholding. It is separate from reimbursements for specific medical expenses. If the parent later obtains insurance at a reasonable cost, either party can seek to modify the order to replace cash medical support with an insurance coverage order.
If the parent providing insurance loses coverage — through job loss, a change in plans, or other reasons — TFC §154.182(d) requires that parent to notify the other parent and the court within 15 days. At that point, either party can seek modification of the medical support order. Failure to notify is a separate violation of the order.
When coverage lapses and the child has unmet medical needs, the court may enter temporary orders requiring cash medical support or requiring the parent to obtain replacement coverage. There is no automatic transition — a modification must be filed.
Even with insurance, children have out-of-pocket medical costs: copays, deductibles, co-insurance, and expenses for services not covered by the plan. Texas child support orders typically address these "uninsured medical expenses" in one of two ways:
| Division Method | How It Works |
|---|---|
| 50/50 Split | Each parent pays half of all uninsured medical expenses. Common in cases where incomes are roughly equal or the order is silent on the specific formula. |
| Pro-Rata Split | Expenses are divided in proportion to each parent's net resources. If the obligor has 60% of the combined net resources, they pay 60% of uninsured expenses. |
The paying parent has the right to receive documentation (an Explanation of Benefits and itemized billing) within 30 days of the expense and must reimburse within 30 days of receiving proper documentation. Failure to submit documentation timely can affect the right to reimbursement.
Medical support under TFC §154.181 encompasses all health care, including dental and vision, although courts frequently address them separately. Dental and vision insurance are treated the same way as health insurance: if available at a reasonable cost through an employer, the court may order them included. If not, cash medical support may cover dental and vision expenses as well.
Courts in Collin County commonly include a provision specifying that dental and vision expenses are uninsured medical expenses subject to the same division formula as other out-of-pocket healthcare costs.
A child with a disability or chronic medical condition may have medical expenses that far exceed what a standard 50/50 division covers. Under TFC §154.302, the court may order additional support specifically tied to the child's extraordinary medical needs. This can include therapy costs, medications, specialized equipment, and in-home care.
Courts look at the nature of the condition, projected costs, the child's expected longevity of need, and each parent's ability to contribute. These cases often require medical documentation and, in more complex situations, expert testimony about projected future costs.
Medical support can be modified under the same standards as base child support — a material and substantial change in circumstances, or the three-year rule. Common triggers for medical support modification include:
The court orders cash medical support — an additional monthly payment on top of base child support, calculated based on what is fair and reasonable given the parties' resources. If a parent later obtains access to insurance at a reasonable cost, the order can be modified to replace cash medical support with an insurance requirement.
No. Typically, one parent is ordered to provide coverage. If both parents have access to insurance, the court selects the plan that offers the best coverage at the most reasonable cost for the child, considering network access and plan quality.
Yes — but reimbursement obligations still apply. If one parent pays a medical expense using an HSA or FSA, the other parent still owes their share of the out-of-pocket cost (not the full amount, since the HSA/FSA may have provided a tax benefit). Courts handle these situations on the facts; consult an attorney if a dispute arises.
Disputes over whether an expense is medically necessary are resolved by the court if the parties cannot agree. Cosmetic procedures, elective treatments, and experimental therapies not covered by insurance are not automatically reimbursable by the other parent. The standard is typically whether a reasonable medical practitioner would recommend the treatment as necessary for the child's health.
Required in every order
TFC §154.181
Insurance available at reasonable cost (<9% of annual resources)
→ Order coverage
No insurance available at reasonable cost
→ Order cash medical support
Uninsured expenses
Divided 50/50 or pro-rata based on net resources
Documentation deadline
Submit within 30 days; reimburse within 30 days of receipt
Disagreements about what counts as a covered expense — or what "reasonable cost" means — are among the most common post-decree family law conflicts. Lynda Landers can advise on your rights and help you enforce or modify medical support orders.
Whether you're negotiating initial terms, disputing uninsured expense reimbursements, or seeking a modification, Lynda Landers has the experience to guide you.
Schedule a Consultation Call (972) 529-5707