DEPARTMENT OF HEALTH & HUMAN SERVICES 
Health Care Financing Administration  
 Center for Medicaid and State Operations 
7500 Security Boulevard 
Baltimore, MD 21244-1850 
March 22, 1999   
Dear TANF Administrators, State Medicaid Directors, and CHIP Directors:   
Through an ongoing strategy to reform welfare, the Administration has fought to continue efforts to support low-income 
families, especially those trying to make the transition from welfare to self-sufficiency. As part of these efforts, it is 
critical that progress is made towards increasing the number of Americans with health insurance. The delinkage of 
Medicaid from cash assistance and declining welfare caseloads have created both challenges and opportunities for 
providing this support for working families. It is important that we use effective strategies and find new ways to reach 
children and families outside, as well as through, the welfare system.   
In order to help policy-makers overcome these challenges, and to realize the potential of these opportunities, we have 
developed the enclosed guide, "Supporting Families in Transition: A Guide to Expanding Health Coverage in the Post-
Welfare Reform World." This guide contains information regarding processes and procedures that will help ensure as 
many children and families as possible obtain health insurance.   
In a letter we sent you on June 5, 1998 (http://www.hcfa.gov/medicaid/wrdl605.htm), we encouraged you to coordinate 
both the administration of, and eligibility for, your TANF and Medicaid programs. In that letter, we highlighted states 
responsibilities to establish and maintain Medicaid eligibility for families and children affected by welfare reform, and we 
also outlined the broad flexibility the statute affords you to expand eligibility. Through the enclosed guide, we are 
providing additional information to help you accomplish these important goals.   
In addition to explaining state options and suggesting appropriate strategies, the guide summarizes the application and 
enrollment requirements for the Medicaid program. Two of the most critical requirements are that States must:   
Provide Medicaid applications upon request. Based on Medicaid regulations (42 CFR 435.906), the Department of 
Health and Human Services (DHHS) has determined that states using joint TANF-Medicaid applications must furnish a 
Medicaid application immediately upon request and may not impose a waiting period before providing the application for 
Medicaid.   
Process Medicaid applications without delay. States must assure that an application for Medicaid is processed quickly 
and not delayed by any TANF requirement. In states where TANF application or eligibility is delayed (i.e., families 
receive diversionary assistance or face any other initial administrative steps), the state must process the joint application 
immediately to determine Medicaid eligibility.   
In addition to issuing the guide, we will be expanding our technical assistance efforts to states to ensure that TANF 
programs are designed and implemented so that children and their families are informed about Medicaid and CHIP and 
enrolled when eligible. To focus our efforts more effectively, we will work with states to review their welfare and 
Medicaid eligibility and enrollment procedures. This process will help us assist state agencies in improving their practices, 
it will further help us by identifying successful models of coordination that can be shared with other states.   
We recognize the new needs for outreach, accessibility, and coordination that have arisen from the delinkage of Medicaid 
from the welfare system, and the growing number of working families unlikely to enter the welfare office but likely to be 
eligible for Medicaid. In light of these new challenges, we are committed to working with you to establish the most 
effective Medicaid application and enrollment procedures for low-income families with children.   
We look forward to continuing this very important work with you and to charting the gains we make together in 
improving the health coverage of all low-income children and families, and in supporting the transitions of families from 
welfare to self-sufficiency. In the meantime, please contact your HCFA or ACF Regional Administrator or your Regional 
Director with any questions or for additional information.   
Sincerely,   
Olivia Golden  Assistant Secretary  Administration for Children and Families   
Nancy Ann Min DeParle  Administrator  Health Care Financing Administration