About three in four of the roughly 9.7 million non-resident parents are fathers. From January 2027, under new federal work-requirement legislation, Medicaid coverage for many of those parents will depend on whether their states actually recognize them as parents. The Centers for Medicare & Medicaid Services (CMS) have exempted parents of children 13 and under from work requirements, defining parent as someone who “provides some level of care” to the child, which includes a large share of parents living apart. As things stand, however, there is a real danger that parents providing a considerable amount of care to their children, but in a second home, will be left out due to state implementation.
In this brief we recommend that states consider a range of measures to include parents, including:
Work to ensure that all parents providing care are aware of their potential eligibility for exemption, for example through public-facing screeners designed to raise awareness.
Adopt a clear definition of “some level of care” that recognizes care across households.
Add a question to the Medicaid application about children under 14 whose primary residence may be listed at another address.
Use child support (IV-D) records and custody orders as documentation where possible.
None of these requires federal action, new money, or any change to the rule as written. In the 42 impacted states and Washington, D.C., the question of whether a non-resident parent keeps their coverage next year is largely in state hands, and is being decided now.
What the new rule says
The 2025 reconciliation law (Pub. L. 119-21, section 71119) added section 1902(xx) to the Social Security Act. From January 1, 2027, adults aged 19 to 64 covered through the Affordable Care Act (ACA) Medicaid expansion must show 80 hours a month of work, community service, a work program or half-time study, or monthly income equal to at least 80 hours at the federal minimum wage (currently $580). Those who cannot do so will lose coverage.
The statute excludes “a parent, guardian, caretaker relative, or family caregiver … of a dependent child 13 years of age and under or a disabled individual.” CMS’s interim final rule (91 FR 33348, June 3, 2026) defines those terms at 42 CFR 435.554(a):
Parent means an individual with the legal status of a mother or father, including by adoption, in accordance with applicable State law, who provides some level of care to a dependent child or disabled individual.
Caretaker relative means a relative of a dependent child … by blood, adoption, or marriage with whom the child … is living, who assumes primary responsibility for the dependent child’s … care.
Dependent child means a child 13 years of age or under who relies on another individual for care.
The preamble is explicit that the two categories differ (91 FR 33367): “Because the statute separately lists ‘parent’ in addition to ‘caretaker relative’ … we interpret ‘parent’ to mean something different.”
In other words, a parent does not need to live with the child to qualify for the exemption. The floor is set as follows: “the parent must provide some level of care … For example, an estranged parent without a relationship with their child would not be considered a specified excluded individual.”
CMS does not define “some level of care” any further. That is left to states to decide. This will be a consequential decision, potentially impacting thousands of non-resident parents.
How non-resident parents may fall through the cracks
Medicaid has never seen non-resident parents as parents. Before the ACA expansion, the parental eligibility category generally required living with a dependent child, so parents living apart from their children often had no route to coverage, however low their income. Expansion in 2014 covered many of these parents, but as low-income adults, rather than through the parent eligibility category. That is why they are invisible in the data: the Urban Institute projects 1 million fathers on expansion coverage but cannot say how many are non-resident, and KFF records 78% of adults in the coverage gap as having “no dependent children,” a measure that counts only children in the home (Urban Institute, 2025; KFF, July 2026).
“States should rely on household composition information collected at application and available in their eligibility system to verify an individual is a parent or a caretaker relative whenever possible.”
In many cases, information on household composition can miss parents who live in a different household from their children; the state may never in fact ask directly whether the applicant is a parent. A father whose ten-year-old lives with her mother across town likely has no child in his household record. If the eligibility system looks only for children living in the applicant’s household, it could overlook a parent who cares for a child living elsewhere, say providing 40% of their care, and mistakenly subject them to the work requirement.
Through 2027, states may accept self-attestation of status for the purposes of allowing exclusion from the requirement. Starting January 1, 2028, where the state cannot verify exclusion status from its own data, it “must require documentation when reasonably available.” The key questions are how “some level of care” is defined and captured for a parent who lives elsewhere, and relatedly what documentation will serve to justify an exclusion.
Poorer parents most affected
The parents most likely to be affected here are low-earning, unstably employed adults with young children who do not live with them, most of them fathers. Low-income fathers overall already face gaps in health coverage: an Urban Institute analysis found that in 2022, 31% of fathers living with children under age 3 in families below 138% of the federal poverty level were uninsured, compared with 17% of mothers in the same group (Urban Institute, 2024). A parent working 80 hours a month, or earning $580, already complies with work requirements and needs no exemption. The exclusion matters for a parent with a child 13 or under who is between jobs, in seasonal or informal work, or returning from incarceration. This is a narrow group, but it is not an elusive one: it is the same population state child support agencies serve with orders and wage garnishment. States often know who these parents are.
Coverage for these parents is not only a health question. Lindsey Bullinger’s study of the ACA expansions found that child support payments rose in expansion states, with payments on arrears up 8.5% and current support up 2.2%, and unmarried mothers 8.6% more likely to receive any support (Bullinger, 2021, Journal of Policy Analysis and Management). A parent who is not being pursued for an emergency room bill is a parent who can pay child support. A state that drops these parents from Medicaid in 2027 is likely, then, to see some losses on the child support front.
Recommendations
There are a number of steps that states can take, both in the short term in the run up to the implementation of the requirements on January 1, 2027, during the first year of the policy’s implementation, and before the formalization of rules that will take effect on January 1, 2028.
Raise awareness and ensure accurate screening for exclusion on the basis of care
States can act immediately to ensure parents are aware of their eligibility. They are required to inform potentially impacted enrollees. Many are also conducting outreach programs to raise awareness of the new work requirements as well as grounds for exclusion. They should strive to ensure that all parents providing care for children 13 and under know about their eligibility, whether they live with them or not. This message should appear consistently in notices, websites, and other outreach materials.
Public-facing screeners are a major part of this effort. They can help parents understand whether the work requirement applies to them, but unclear or incorrect questions may lead eligible parents to believe they do not qualify for an exclusion. So far states’ implementation here is mixed, at best.
Georgetown’s Center for Children and Families tracks state consumer materials on the work requirement, including the quick pre-screening tools that let people check whether they are likely to be exempt (State Webpages and Consumer Materials on Work Reporting, updated October 12, 2026). Of the 43 jurisdictions in the tracker, 15 have a screener live and two (Idaho and Maine) list one as coming soon. Screeners are not applications and do not decide eligibility, but for many people they will be the first answer they get. We worked through each one on October 15 to see how it handles the parent question.
Of the 15 state screening tools online as of October 15, 2026, only Massachusetts describes the parent exemption the way CMS wrote it. Four tell a parent whose child lives elsewhere that the exemption does not apply to them. The other ten say nothing explicitly either way.
Figure 1
Colorado is one of the starkest cases. A parent can tick the box, but the next screen asks whether they live with the child, and if they do not, and answer honestly, the result is: “You may need to complete work requirements.” Alaska, Indiana and Wisconsin build the same condition into the question itself. All four misstate the federal rule, which CMS wrote precisely so that a parent need not live with the child.
Other screeners are ambiguous. A father who has his children every other weekend, asked whether he is a “primary caregiver” (New Jersey, West Virginia) or a “caretaker relative” (Missouri, Vermont), may reasonably assume the question is not about him. Massachusetts that shows the fix takes one sentence: “I am a parent who provides care to my child who is younger than 14.” States developing or revising their screeners can adopt that wording at no cost, and the four with a co-residence condition should remove it.
Adopt a clear definition of “some level of care.”
As noted above, the screening tools are not the basis for actual decisions, which will be made according to state rules that are being drafted. In the spirit of promoting constructive discussion, AIBM proposes the following model language for state Medicaid manuals or rules:
Consistent with the definition of “parent” in 42 CFR 435.554(a), a parent may provide “some level of care” to a dependent child whether or not they live together. Care may include supervising the child, preparing meals, helping with schoolwork, transporting the child to school or appointments, or attending to the child’s health needs. These examples are not exhaustive. A parent need not be the child’s primary caregiver or have a formal custody or parenting-time agreement.
The definition deliberately tracks CMS’s own boundary. Requiring legal agreements would exclude parents who pay support and see their children informally. They are the majority: 73% of non-resident fathers have no written visitation agreement.
Ask the question.
States are updating their Medicaid renewal applications and online portals and can add one question along the lines of this: “Do you have any children age 13 or under who do not live with you?” Without this, relying on household composition alone risks missing nonresident parents. Adding a question should come with minimal costs and generates a record that could be used as a part of the 2028 documentation rule.
Use records the state already holds for documentation.
Specify that from January 2028, when documentation is required under the federal law, that the following count as documentation of parent status and care: a custody, parenting-time or child support order from any court; or the state IV-D child support agency’s own case and payment records. State Medicaid and child support agencies already share data for the medical support and cooperation requirements. The same match, run in the other direction, can help identify the non-resident parent. These records can help establish parenthood and care, but parents without a formal order should also have a practical way to establish care.
The opportunity for states
CMS chose to define parent separately from “caretaker relative”, allowing parents who do not live with the child to be covered, and it set the floor as being above that of an “estranged parent”. A state that chooses to require co-residence by relying on household composition alone is not applying the rule; it is narrowing it by omission. Our model definition applies the rule as written.
Depending on their data systems, the cost to states of gathering this information should be low, and the fiscal direction favors action. A non-resident parent exempted from the work requirement stays in the expansion group, where the federal government pays 90% of their coverage. The alternative, losing them from coverage and reacquiring them later through an emergency room or a reinstatement, is the more expensive path. States also avoid the administrative cost of processing compliance for a group that is exempt, which the preamble itself identifies as a reason to use consistent definitions across programs.
Conclusion
States increasingly need to know how much care a non-resident parent is actually providing. Child support guidelines need to know, in order to adjust orders for parenting time. This is one reason that it would make sense, in the longer term, for every child support order to be accompanied by a parenting-time order, as Texas already requires.
But the new Medicaid rule adds considerable urgency to the need to answer this question. It is in the interests of states themselves, as well as families, to ensure that non-resident parents are properly included. Swift action is required from state-level policymakers.
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PolicyHealth, Fatherhood & Family, Employment
Counting caring parents: Defining “some level of care” for the Medicaid work requirement
Overview
About three in four of the roughly 9.7 million non-resident parents are fathers. From January 2027, under new federal work-requirement legislation, Medicaid coverage for many of those parents will depend on whether their states actually recognize them as parents. The Centers for Medicare & Medicaid Services (CMS) have exempted parents of children 13 and under from work requirements, defining parent as someone who “provides some level of care” to the child, which includes a large share of parents living apart. As things stand, however, there is a real danger that parents providing a considerable amount of care to their children, but in a second home, will be left out due to state implementation.
In this brief we recommend that states consider a range of measures to include parents, including:
None of these requires federal action, new money, or any change to the rule as written. In the 42 impacted states and Washington, D.C., the question of whether a non-resident parent keeps their coverage next year is largely in state hands, and is being decided now.
What the new rule says
The 2025 reconciliation law (Pub. L. 119-21, section 71119) added section 1902(xx) to the Social Security Act. From January 1, 2027, adults aged 19 to 64 covered through the Affordable Care Act (ACA) Medicaid expansion must show 80 hours a month of work, community service, a work program or half-time study, or monthly income equal to at least 80 hours at the federal minimum wage (currently $580). Those who cannot do so will lose coverage.
The statute excludes “a parent, guardian, caretaker relative, or family caregiver … of a dependent child 13 years of age and under or a disabled individual.” CMS’s interim final rule (91 FR 33348, June 3, 2026) defines those terms at 42 CFR 435.554(a):
Parent means an individual with the legal status of a mother or father, including by adoption, in accordance with applicable State law, who provides some level of care to a dependent child or disabled individual.
Caretaker relative means a relative of a dependent child … by blood, adoption, or marriage with whom the child … is living, who assumes primary responsibility for the dependent child’s … care.
Dependent child means a child 13 years of age or under who relies on another individual for care.
The preamble is explicit that the two categories differ (91 FR 33367): “Because the statute separately lists ‘parent’ in addition to ‘caretaker relative’ … we interpret ‘parent’ to mean something different.”
In other words, a parent does not need to live with the child to qualify for the exemption. The floor is set as follows: “the parent must provide some level of care … For example, an estranged parent without a relationship with their child would not be considered a specified excluded individual.”
CMS does not define “some level of care” any further. That is left to states to decide. This will be a consequential decision, potentially impacting thousands of non-resident parents.
How non-resident parents may fall through the cracks
Medicaid has never seen non-resident parents as parents. Before the ACA expansion, the parental eligibility category generally required living with a dependent child, so parents living apart from their children often had no route to coverage, however low their income. Expansion in 2014 covered many of these parents, but as low-income adults, rather than through the parent eligibility category. That is why they are invisible in the data: the Urban Institute projects 1 million fathers on expansion coverage but cannot say how many are non-resident, and KFF records 78% of adults in the coverage gap as having “no dependent children,” a measure that counts only children in the home (Urban Institute, 2025; KFF, July 2026).
The preamble to the new rule tells states how to find parents:
“States should rely on household composition information collected at application and available in their eligibility system to verify an individual is a parent or a caretaker relative whenever possible.”
In many cases, information on household composition can miss parents who live in a different household from their children; the state may never in fact ask directly whether the applicant is a parent. A father whose ten-year-old lives with her mother across town likely has no child in his household record. If the eligibility system looks only for children living in the applicant’s household, it could overlook a parent who cares for a child living elsewhere, say providing 40% of their care, and mistakenly subject them to the work requirement.
Through 2027, states may accept self-attestation of status for the purposes of allowing exclusion from the requirement. Starting January 1, 2028, where the state cannot verify exclusion status from its own data, it “must require documentation when reasonably available.” The key questions are how “some level of care” is defined and captured for a parent who lives elsewhere, and relatedly what documentation will serve to justify an exclusion.
Poorer parents most affected
The parents most likely to be affected here are low-earning, unstably employed adults with young children who do not live with them, most of them fathers. Low-income fathers overall already face gaps in health coverage: an Urban Institute analysis found that in 2022, 31% of fathers living with children under age 3 in families below 138% of the federal poverty level were uninsured, compared with 17% of mothers in the same group (Urban Institute, 2024). A parent working 80 hours a month, or earning $580, already complies with work requirements and needs no exemption. The exclusion matters for a parent with a child 13 or under who is between jobs, in seasonal or informal work, or returning from incarceration. This is a narrow group, but it is not an elusive one: it is the same population state child support agencies serve with orders and wage garnishment. States often know who these parents are.
Coverage for these parents is not only a health question. Lindsey Bullinger’s study of the ACA expansions found that child support payments rose in expansion states, with payments on arrears up 8.5% and current support up 2.2%, and unmarried mothers 8.6% more likely to receive any support (Bullinger, 2021, Journal of Policy Analysis and Management). A parent who is not being pursued for an emergency room bill is a parent who can pay child support. A state that drops these parents from Medicaid in 2027 is likely, then, to see some losses on the child support front.
Recommendations
There are a number of steps that states can take, both in the short term in the run up to the implementation of the requirements on January 1, 2027, during the first year of the policy’s implementation, and before the formalization of rules that will take effect on January 1, 2028.
Raise awareness and ensure accurate screening for exclusion on the basis of care
States can act immediately to ensure parents are aware of their eligibility. They are required to inform potentially impacted enrollees. Many are also conducting outreach programs to raise awareness of the new work requirements as well as grounds for exclusion. They should strive to ensure that all parents providing care for children 13 and under know about their eligibility, whether they live with them or not. This message should appear consistently in notices, websites, and other outreach materials.
Public-facing screeners are a major part of this effort. They can help parents understand whether the work requirement applies to them, but unclear or incorrect questions may lead eligible parents to believe they do not qualify for an exclusion. So far states’ implementation here is mixed, at best.
Georgetown’s Center for Children and Families tracks state consumer materials on the work requirement, including the quick pre-screening tools that let people check whether they are likely to be exempt (State Webpages and Consumer Materials on Work Reporting, updated October 12, 2026). Of the 43 jurisdictions in the tracker, 15 have a screener live and two (Idaho and Maine) list one as coming soon. Screeners are not applications and do not decide eligibility, but for many people they will be the first answer they get. We worked through each one on October 15 to see how it handles the parent question.
Of the 15 state screening tools online as of October 15, 2026, only Massachusetts describes the parent exemption the way CMS wrote it. Four tell a parent whose child lives elsewhere that the exemption does not apply to them. The other ten say nothing explicitly either way.
Figure 1
Colorado is one of the starkest cases. A parent can tick the box, but the next screen asks whether they live with the child, and if they do not, and answer honestly, the result is: “You may need to complete work requirements.” Alaska, Indiana and Wisconsin build the same condition into the question itself. All four misstate the federal rule, which CMS wrote precisely so that a parent need not live with the child.
Other screeners are ambiguous. A father who has his children every other weekend, asked whether he is a “primary caregiver” (New Jersey, West Virginia) or a “caretaker relative” (Missouri, Vermont), may reasonably assume the question is not about him. Massachusetts that shows the fix takes one sentence: “I am a parent who provides care to my child who is younger than 14.” States developing or revising their screeners can adopt that wording at no cost, and the four with a co-residence condition should remove it.
Adopt a clear definition of “some level of care.”
As noted above, the screening tools are not the basis for actual decisions, which will be made according to state rules that are being drafted. In the spirit of promoting constructive discussion, AIBM proposes the following model language for state Medicaid manuals or rules:
Consistent with the definition of “parent” in 42 CFR 435.554(a), a parent may provide “some level of care” to a dependent child whether or not they live together. Care may include supervising the child, preparing meals, helping with schoolwork, transporting the child to school or appointments, or attending to the child’s health needs. These examples are not exhaustive. A parent need not be the child’s primary caregiver or have a formal custody or parenting-time agreement.
The definition deliberately tracks CMS’s own boundary. Requiring legal agreements would exclude parents who pay support and see their children informally. They are the majority: 73% of non-resident fathers have no written visitation agreement.
Ask the question.
States are updating their Medicaid renewal applications and online portals and can add one question along the lines of this: “Do you have any children age 13 or under who do not live with you?” Without this, relying on household composition alone risks missing nonresident parents. Adding a question should come with minimal costs and generates a record that could be used as a part of the 2028 documentation rule.
Use records the state already holds for documentation.
Specify that from January 2028, when documentation is required under the federal law, that the following count as documentation of parent status and care: a custody, parenting-time or child support order from any court; or the state IV-D child support agency’s own case and payment records. State Medicaid and child support agencies already share data for the medical support and cooperation requirements. The same match, run in the other direction, can help identify the non-resident parent. These records can help establish parenthood and care, but parents without a formal order should also have a practical way to establish care.
The opportunity for states
CMS chose to define parent separately from “caretaker relative”, allowing parents who do not live with the child to be covered, and it set the floor as being above that of an “estranged parent”. A state that chooses to require co-residence by relying on household composition alone is not applying the rule; it is narrowing it by omission. Our model definition applies the rule as written.
Depending on their data systems, the cost to states of gathering this information should be low, and the fiscal direction favors action. A non-resident parent exempted from the work requirement stays in the expansion group, where the federal government pays 90% of their coverage. The alternative, losing them from coverage and reacquiring them later through an emergency room or a reinstatement, is the more expensive path. States also avoid the administrative cost of processing compliance for a group that is exempt, which the preamble itself identifies as a reason to use consistent definitions across programs.
Conclusion
States increasingly need to know how much care a non-resident parent is actually providing. Child support guidelines need to know, in order to adjust orders for parenting time. This is one reason that it would make sense, in the longer term, for every child support order to be accompanied by a parenting-time order, as Texas already requires.
But the new Medicaid rule adds considerable urgency to the need to answer this question. It is in the interests of states themselves, as well as families, to ensure that non-resident parents are properly included. Swift action is required from state-level policymakers.
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