MEDICAID CHIP-RELATED EXPANSION:
Cooperation with the State in Establishing Paternity and in Obtaining Medical Support and Payments. Cooperation is a condition of eligibility under Medicaid which applies to Medicaid CHIP expansions. Applicants/recipients, with the exception of poverty level pregnant women, must cooperate in order to be eligible for Medicaid, unless there is "good cause" for failure to cooperate. Cooperation is part of the assignment of rights provision of section 1912 of the Social Security Act governing the third party liability (TPL) process.
Denial or Termination of Medicaid Eligibility. Medicaid eligibility cannot be denied or terminated for a child due to the refusal of another person to: 1) assign to the State his/her rights or the rights of any individual eligible on whose behalf he/she has the legal authority to execute an assignment of rights, 2) cooperate in establishing paternity and in obtaining medical support and payments, and 3) cooperate in identifying and providing information to assist the State in pursuing any third party. Therefore, failure of a parent to cooperate will not affect the eligibility of the child.
Note: Because eligibility under Medicaid is no longer contingent upon receipt of AFDC, the size of a child's family is never reduced on the basis that a parent refused to cooperate in establishing paternity and pursuing support. The family size and need remain the same for Medicaid purposes, whether or not the parent cooperates.
Information on Non-custodial parent. States must identify and pursue TPL, including medical child support, whether or not an applicant actively cooperates. The State is responsible for seeking information about the non-custodial parent during the application process. This doesn't necessarily mean that this information must be collected in the "simplified application" itself as long as it is obtained in the "application process." The State can ask for this information at any time during the application process. The last step in the application process is the notification of the determination of eligibility.
Referrals to the State CSE agency. CSE agencies are required to petition courts for medical support from a non-custodial parent and to provide other services to all families with a non-custodial parent who receive Medicaid. For these agencies to provide the required services, they need to know who these individuals are that need these services. Therefore, the State Medicaid agency should coordinate with the CSE agency to ascertain what information is necessary and refer appropriate cases to them for services, unless the recipient already has satisfactory health insurance other than Medicaid or is receiving adequate medical support from the non-custodial parent. When working out the referral arrangements with the CSE agency, the State should develop procedures that do not pose a barrier to simplifying the Medicaid application and enrollment process.
The State is not required to notify the custodial parent in advance of the referral if the custodial parent cooperated by providing the information. However, if the custodial parent did not cooperate and the information was obtained elsewhere, the custodial parent must be provided the opportunity to show "good cause" for not providing the information and why there should not be a referral, taking into consideration the best interests of the individuals involved.
CHIP - SEPARATE STATE HEALTH INSURANCE PROGRAM REQUIREMENTS
Federal CHIP Requirements. Under a program governed only by title XXI, there are no federal requirements for cooperation and/or coordination with CSE. A State could, however, impose requirements of its own. In other words, if a State chooses to expand title XXI through Medicaid, all of the above Medicaid requirements will apply (because the newly covered children will be Medicaid beneficiaries) but, if the State chooses to implement CHIP through a separate State health insurance program, the State is not subject to Medicaid requirements and there are no independent federal CHIP requirements.
Last Updated January 12, 1999