The proposed rules published on January 22, 2013 clarify that Medicaid eligibility cannot be delayed for a parent, and never denied for a child, while the parent cooperates in obtaining medical support or in establishing paternity of a child. The rule does not change the fact that cooperation is a condition of eligibility for the parent. Instead it outlines the process whereby states must not hold up the Medicaid application until the necessary steps are taken to establish medical support or paternity.  We fully support this proposal, which will ensure that low-income parents, and particularly their children, can obtain coverage without delays that might ensue if full cooperation with child support authorities is required upfront.

What does the proposed rule do? Subject to final rulemaking, the updated regulations promote streamlined eligibility and address past problems by outlining the following process:

• A parent or caretaker applying for Medicaid coverage must agree to cooperate in establishing paternity or obtaining medical support. Applicants who do not agree can be denied Medicaid. The eligibility of children and pregnant women is not dependent on cooperation.  Cooperation is also not required for CHIP or subsidized coverage offered through the exchange.
• States must not suspend the eligibility and enrollment process for either the parent/caretaker or child pending cooperation. Enforcement of state requirements that constitute cooperation should follow, not delay, eligibility and enrollment.
• If the parent does not cooperate, they will lose coverage; however, a child cannot be denied coverage, even if the parent or caretaker does not cooperate.
• Good cause waivers may be established that exempt the parent from cooperating, if cooperation is against the best interests of the child.

Why is this clarification important? Medical support is a form of child support often determined by a custody order. When the relationship between parents is amicable, coordinating medical support is just another aspect of sharing responsibility for the health and wellbeing of their child. Unfortunately, these situations are not always amicable. In situations where paternity has not been established, the custodial parent must also cooperate with the state in doing so, as well as pursuing medical support.

States often hold up the Medicaid application pending cooperation. This can impact the child’s enrollment, particularly if other information is needed and the parent is not clear about what is required to process eligibility for the child only. In the most extreme cases, providing information about an estranged parent can put the child and custodial parent at risk. And while the requirement to cooperate with medical support can be waived for good cause (for example, in cases of domestic violence), a parent may not be aware of such exceptions. These situations have proven to be barriers to coverage for children, even though failure to cooperate should only disqualify the parent from Medicaid coverage – not the child.

What should be done to assure smooth implementation of the new rules? Child health advocates may want to work with their Medicaid and child support agencies to identify the types of situations that qualify for good cause waivers. Having clear guidelines and examples will help ensure that the system works as intended. Additionally, it’s important to educate the stakeholders to ensure that the process is fully implemented and consistently applied.

In states that are creating their own version of the single, streamlined application, advocates can suggest language to make sure that parents understand what is required of them. An example of such language is the current application for health coverage known as Husky or Charter Oak in Connecticut:

“Section E: Parents Who Do Not Live in the Household –

If you are a parent or a caretaker relative living with a child and you want health coverage for yourself, you must agree to cooperate with child support. This means that you will give us information about parents who do not live in the home and help us pursue medical support. If you do not agree to cooperate, you cannot get HUSKY or Charter Oak coverage for yourself, however, your children can still qualify for HUSKY. You may ask for an exemption from this requirement if you feel there is a threat of domestic violence. Even if you do not want health coverage for yourself, we can help you obtain child support.” 

The model application released by HHS recently addresses cooperation this way under a section labeled “If anyone on this application is eligible for Medicaid:

“Does any child on this application have a parent outside of the home? Yes/No

If yes, I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell Medicaid and I may not have to cooperate.”

Clarification of the process for securing cooperation for medical support is just one small example of the many positive changes that are coming to Medicaid in 2014, regardless of whether a state expands Medicaid coverage to the lowest-income adults. While Medicaid stakeholders work diligently to convince state policymakers to make rational, not ideological, choices in implementing the ACA, these small changes are a welcomed reminder of the many ways the law streamlines the process to advance coverage.