DEPARTMENT OF HEALTH & HUMAN SERVICES Health Care Financing Administration 
Center for Medicaid and State Operations 7500 Security Boulevard Baltimore, MD 21244-1850  
December 19, 2000  
Dear State Medicaid Director:  
Over the past year, questions have arisen about Medicaid policy regarding establishing paternity 
and obtaining and pursuing medical support and payments. The Child Support Enforcement 
(CSE) program can provide valuable assistance to families seeking health care, as well as 
financial support, for their children. However, many States and organizations doing outreach and 
enrollment have identified paternity and medical support questions on Medicaid applications as a 
barrier to enrollment of eligible children. This letter explains the Federal Medicaid requirements 
and options pertaining to paternity and medical support and briefly describes the child support 
enforcement services available to families receiving Medicaid.  
Under Federal law, a parent's cooperation in establishing paternity, assigning rights to medical 
support and payments, and providing information about liable third parties cannot be required as a 
condition of a child's eligibility for Medicaid. Therefore, States are not required to ask about 
paternity or to seek cooperation in pursuing medical support and third party payments when an 
application for Medicaid is filed, or a redetermination is performed, only on behalf of a child. If a 
State does ask about paternity or otherwise pursues medical support in the context of an application 
on behalf of a child, it must advise the parent or other individual completing the application on 
behalf of the child that such information and cooperation is not required in order for the child to be 
enrolled in Medicaid. Cooperation is, however, a condition of eligibility for a parent, unless the 
parent meets one of the exceptions described below. And for all applications, States must comply 
with the third party information collection and rights assignment provisions under Section 
1902(a)(25) of the Act.  
Background  
Several provisions in Federal Medicaid law pertain to paternity establishment, medical support, and third party 
liability for medical services. Section 9142 of the Omnibus Budget Reconciliation Act (OBRA) of 1987, as 
reiterated by Section 301 of the Personal Responsibility and Work Opportunity Reconciliation  
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Act of 1996 (PRWORA), requires State CSE agencies to provide child support services, where 
appropriate, to families who receive Medicaid. These services include establishing paternity, 
locating noncustodial parents, and establishing and enforcing child support and medical support 
obligations. These services are available to all families receiving Medicaid whether or not the 
parent is obligated to cooperate with the CSE agency as a condition of eligibility for Medicaid. 
Paternity may be established voluntarily without CSE referral if done at the hospital, through the 
State vital records office, or in other social service settings.  
Paternity establishment is the necessary first step in the support enforcement process. In addition to 
child support and medical support, paternity establishment may result in other financial benefits for 
a child, including Social Security dependents benefits, pension benefits, veterans benefits, and  possible rights of inheritance. Furthermore, paternity establishment may give a child social and 
psychological advantages and a sense of family heritage, be a first step in creating a psychological 
and social bond between father and child, and provide important medical history information.  
Cooperation with CSE is a requirement for some individuals' Medicaid eligibility. Section 
1912(a)(1) of the Act requires individuals applying for Medicaid who have the legal capacity to 
execute assignments to assign the State their right to support and payment for medical care from a 
third party. Also, to the extent that they have the legal authority to do so, Section 1912 requires 
these individuals, with respect to any other Medicaid eligible individual, to assign the State their 
rights to support and payment for medical care by any third party. Finally, these individuals, except 
as described below, are required as a condition of eligibility to cooperate with the State in 
establishing paternity, obtaining medical support and payments, and in identifying and providing 
information to assist the State in pursuing third parties who may be liable for payment.  
A related provision of the law, Section 1902(a)(25) of the Act, requires States to take reasonable 
measures to determine whether a third party may be liable for the medical care and services 
provided to a Medicaid beneficiary and to collect third party information at the time of any 
determination or redetermination of Medicaid eligibility. It also requires States to adopt laws, 
which automatically assign to the State the individual's rights to payment for medical care by third 
parties, whether or not the individual has executed an assignment of rights under Section 
1912(a)(1).  
 
Applications On Behalf of Parents and Other Adults  
If parents or other adults apply for Medicaid on behalf of themselves and their children, they must 
assign medical support and payment rights to the State and cooperate in establishing paternity, 
obtaining medical support and payments, and providing information about liable third parties as a 
condition of their own eligibility, unless they are exempt. Pregnant women eligible under Section 
1902(l)(1)(A) of the Act (poverty level pregnant women) are exempt from the requirements to 
cooperate in establishing paternity of a child born out of wedlock, and in obtaining medical support 
and payments for themselves and the child born out of wedlock. (These women must, however, 
assign the rights to medical support and payments). In addition, individuals with good cause, as 
described by Federal regulation 42 CFR  
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433.147(c), are exempt from cooperating in establishing paternity, obtaining medical support and 
payment, and pursuing third party liability. Applicants must be effectively informed of these 
exemptions and told that the decision whether or not to cooperate will not affect their child=s 
eligibility for Medicaid.  
Although the establishment of paternity is a requirement for some parents seeking Medicaid, the 
Medicaid agency does not have to solicit information about paternity during the Medicaid 
application process; a simple statement on the application that the parent agrees to cooperate is 
sufficient to meet this requirement. Parents can be given information on how to follow up with  the CSE agency, or the Medicaid agency or CSE can request further information once the 
application process is complete. Parents who are not exempt from the requirement have an 
ongoing obligation to cooperate in order to maintain their eligibility for Medicaid, except during a 
period of Transitional Medicaid (TMA); parents are not required to establish paternity or pursue 
medical support if they are receiving time-limited TMA coverage.  
 
Child-Only Applications  
If a parent or caretaker files an application for Medicaid on behalf of a child only, the 
requirements under Section 1912 do not apply to the parent or caretaker. It is not a condition of the 
child's eligibility that the parent or caretaker assign the child's rights to support and payment and 
cooperate in establishing paternity and pursuing medical support and payment. As a result, States 
are not required by Federal law to ask for cooperation by the parent or caretaker in a child-only 
application. If a State does seek cooperation, the parent or caretaker must be effectively informed 
that the child's eligibility for Medicaid will not be affected if the parent or caretaker chooses not to 
cooperate in establishing paternity and pursuing support at this time. Also, the family size (number 
of individuals in the household) and need standard that are used to determine the child's Medicaid 
eligibility cannot be reduced if the parent or caretaker refuses to cooperate.  
Although the parent is not required to assign the child's rights, Section 1902(a)(25)(H) requires 
States to have laws which automatically assign an individual's rights to payment for medical care 
by third parties to the extent that Medicaid has made a payment. These laws assign to States an 
individual's rights whether or not an assignment was executed. In addition, although a State 
cannot require parents to cooperate in establishing paternity and pursuing medical support when 
only the child is applying for Medicaid, under Section 1902(a)(25)(A) the State must ask the 
parent whether the child has health insurance in order to identify legally liable third party 
resources. This information must be collected at the time of application and redetermination in 
accordance with HCFA regulations at 42 CFR 433.138.  
 
SCHIP Requirements  
There are no Federal requirements for cooperation with CSE under Title XXI State Children's 
Health Insurance Program (SCHIP) rules. If a State chooses to implement SCHIP through 
Medicaid, all of the above Medicaid requirements will apply because the newly covered children 
will be Medicaid beneficiaries. If the State chooses to implement SCHIP through a separate 
child health program, these  
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requirements do not apply. CSE agencies, however, can be a helpful source of information about 
SCHIP and Medicaid coverage for parents of uninsured children who are in contact with CSE. 
Effective coordination with CSE can help States meet their child health coverage enrollment goals.  
 
Child Support Enforcement (CSE) Services   CSE services are available to families who are eligible for Medicaid. States should advise parents 
of these services. Parents who have filed for Medicaid on behalf of a child only are not obligated 
but may choose to utilize CSE services. The Medicaid agency should ensure that families that 
want to take advantage of child support services are referred to the CSE agency.  
HCFA and the Administration on Children and Families (ACF) will continue to work together 
with States to develop and provide models of effective applications, application processes, and 
agency coordination.  
If you or your staff have any questions concerning this letter, please contact Marty Svolos at (410) 
7864582.  
Sincerely,  
/s/  
Timothy M. 
Westmoreland 
Director  
cc:  
HCFA Regional Administrators 
 
HCFA Associate Regional Administrators for Medicaid and State Operations  
State IV-D Directors  
Lee Partridge Director, Health Policy Unit American Public Human Services Association  
Joy Wilson Director, Health Committee National Conference of State Legislatures  
Matt Salo  
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Director of Health Legislation National Governors' Association  
Brent Ewig Senior Director, Access Policy Association of State and Territorial Health Officials  
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