c. Parent, Guardian, Caretaker Relative, or Family Caregiver of a Dependent Child or a Disabled Individual

Section 1902(xx)(9)(A)(ii)(III) of the Act (implemented at § 435.554(c)(3)) establishes a category of specified excluded individuals for “parents, guardians, caretaker relatives, and family caregivers (as defined in section 2 of the RAISE Family Caregivers Act) of a dependent child 13 years of age and under or a disabled individual.” Because each of these subcategories of individuals has different definitions and requirements, the information needed to verify an individual's status as a parent, a guardian, a caretaker relative, or a family caregiver for the purpose of this exclusion, and the reliable information available to the State to do so, varies. For all subcategories, States must design reasonable procedures and use reliable information available to the State to ensure qualifying parents, guardians, caretaker relatives, and family caregivers are identified promptly and determined to be specified excluded individuals excluded from the community engagement requirement. If there is no reliable information available to the State, or the reliable information is not reasonably compatible with the information provided by or on behalf of the individual, the State must seek information from the individual to verify their specified excluded status. Beginning on January 1, 2028, when the State is unable to verify the specified excluded status using reliable information available to the State, or the reliable information is not reasonably compatible with the information provided by or on behalf of the individual, the State must require documentation if documentation is reasonably available. If there is no reasonably available documentation, the State must accept other information sufficient (as determined by the State) to verify eligibility, consistent with § 435.557(b)(2)(iii).

In all instances, the State must verify that the individual receiving care is either a dependent child or a disabled individual, as both of these terms are defined at § 435.554(a) (Please refer to sections II.E.3.e. and f. of this IFC for further information regarding the who is considered a dependent child or disabled individual for the purpose of community engagement and § 435.554(a) for the definition of those terms as they apply to community engagement.) To verify the child's age, States should rely to the greatest extent possible on the household composition data available in their eligibility system. If the age of the individual receiving care is not available in the case record or eligibility system, the State must obtain that information from the applicant or beneficiary.

To verify the disability status of the individual receiving assistance as further discussed in section II.E.3.f. of this IFC, States must attempt to use reliable information available to the State, to the extent the State has consent to access the information of the individual receiving care. Where there is no reliable information available to the State, including if the State does not have consent to access the information of the individual receiving care and the information is therefore unavailable, the State must seek information from the applicant or beneficiary to verify the disability status of the individual receiving care. The State must collect sufficient information to substantiate that the individual receiving care meets the definition of a disabled individual at § 435.554(a). We note that while the State may require that the applicant or beneficiary provide a minimum amount of information necessary to determine that the individual to whom the applicant or beneficiary provides assistance meets the definition of a disabled individual, the State may not require the name of the individual receiving care or other identifying information, and may not determine that an individual does not qualify for the exclusion only because the applicant or beneficiary declines to identify the disabled individual to whom the applicant or beneficiary is providing assistance. If the applicant or beneficiary does not have the disabled individual's consent to release their identifying information to the State, the State must require information from the applicant or beneficiary in the form of a statement or screening tool sufficient to verify the person receiving care meets the definition of a disabled individual.

As described in further detail in this section, States may also need to obtain other information to verify an applicant's or beneficiary's specified excluded individual status, such as the number of hours of care provided. States may use screening questions to identify individuals who may qualify as a specified excluded individual based on their caregiver status and follow up with those who are identified through the screening process to obtain additional information, including documentation (if applicable). However, whenever States have information indicating the individual may qualify for this exclusion, States should attempt to obtain all additional information needed to sufficiently verify an individual's caregiver status in a single request, rather than requiring the individual to fill out numerous forms or respond to multiple requests for additional information. For example, if the State needs information to verify the number of hours of assistance the family caregiver provided in a given month and that the individual to whom the family caregiver provided assistance is disabled, the State should send one request for information seeking ( printed page 33404) documentation (or other needed information in the absence of reasonably available documentation) to verify both criteria whenever possible.

The State must also verify the individual's relationship to the dependent child or disabled individual to confirm the individual is the dependent child's or disabled individual's parent, guardian, caretaker relative, or family caregiver (as defined at § 435.554(a) and implemented at § 435.554(c)(3)). We define guardian to mean an adult appointed by a court to care for and make personal decisions on behalf of an individual who cannot care for themselves, as further detailed in II.E.3.c. of this IFC. Because the definition is dependent on the legal status as determined by a court, the State must require a court order or other legal instrument in accordance with applicable State law to verify an individual's status as a guardian. 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. However, States should be mindful that the terms “parent” and “caretaker relative” assume a slightly different meaning (defined at § 435.554(a)) for purposes of community engagement than they do for general Medicaid eligibility purposes.

Family caregiver as defined at § 435.554(a) means an adult family member or other individual who has a significant relationship with, and who provides care within a broad range of assistance, to a dependent child or a disabled individual. An individual who is a family caregiver as defined at § 435.554(a) is a specified excluded individual if he or she meets one of the following implementing criteria established at § 435.554(c)(3)(i)(A) through (C): (1) the individual primarily resides with a dependent child or disabled individual, as these terms are defined in section II.E.3. of this IFC, for whom he or she provides assistance that occurs on a regular basis and is not solely incidental in nature, (2) the individual is a relative (as specified in the “caretaker relative” definition at § 435.554(a), without regard to the requirements to live with and to assume primary responsibility requirement) of a dependent child or disabled individual as defined earlier for whom he or she provides assistance that occurs on a regular basis and is not solely incidental in nature, and with whom he or she does not reside, or (3) the individual does not reside with and is not a relative (as specified in the “caretaker relative” definition at § 435.554(a), without regard to the requirements to live with or to assume primary responsibility requirement) of the dependent child or the disabled individual, as defined earlier, for whom he or she provides not less than 80 hours of assistance that is not solely incidental in nature per month. We explain in section II.E.3. of this IFC that we view shared residence with or familial relationship to the care recipient as consistent with ongoing caregiving responsibility and as strong evidence of the “significant relationship” specified in the RAISE Family Caregivers Act definition of family caregiver. Thus, individuals meeting either of those criteria are not required to demonstrate provision of a minimum number of caregiving hours but are required to demonstrate that they provide assistance that occurs on a regular basis that is not solely incidental in nature (as described in section II.E.3.h. of this IFC). As such, verifying whether an individual resides with or is related to the dependent child or disabled individual for whom he or she provides assistance is critical to determining if an individual meets the definition of a family caregiver at § 435.554(a) and qualifies as a specified excluded individual under the family caregiver component of section 1902(xx)(9)(A)(ii)(III) of the Act as implemented at § 435.554(c)(3)(i). States should rely on household composition and relationship data collected during the application process and stored in the eligibility system to verify the shared residence or familial relationship when possible. States should only seek additional information from the applicant or beneficiary to verify relationship to or co-residence with the dependent child or disabled individual if the information is not available in the State's system. If the applicant or beneficiary meets the definition of a family caregiver at § 435.554(a) and resides with or is related to the dependent child or disabled individual to whom he or she provides assistance, the State must collect information necessary to verify that the assistance provided by the applicant or beneficiary is provided on a regular basis and is not solely incidental in nature. If the State determines an individual meets the definition of a family caregiver at § 435.554(a) and does not live with and is not related to a dependent child or disabled individual for whom they are providing assistance that is not solely incidental in nature, the State is required also to verify the number of hours of assistance provided and may only determine the individual is a specified excluded individual under the family caregiver component of the exclusion at section 1902(xx)(9)(A)(ii)(III) of the Act if the individual provides no less than 80 hours of assistance in a month. For individuals whose family caregiver status and specified excluded individual status cannot be automatically established through reliable information available to the State, States must obtain sufficient information from the applicant or beneficiary to verify their status as a specified excluded individual under the family caregiver component of the exclusion at section 1902(xx)(9)(A)(ii)(III) of the Act. States must determine what information is sufficient to verify an individual is a family caregiver, but the information must substantiate the State's determination that an individual does or does not satisfy the criteria to be a specified excluded individual on this basis. We also note that, if the individual is ineligible for the exclusion because they provided care for less than the required number of hours, the hours spent providing care are considered unpaid work and must count as such toward the 80 hours required to demonstrate community engagement on the basis of work or a combination of qualifying hour types. See section II.I.6.a. of this IFC for more information about verifying work hours.

In addition to using reliable information available to the State to identify family caregivers who could be specified excluded individuals, screening questions and tools can reduce administrative barriers and speed identification and processing for applicants and beneficiaries who may be specified excluded individuals. States should consider incorporating plain language screening questions in Medicaid applications and other program applications and forms to help identify family caregivers and to help family caregivers identify themselves as being a family caregiver. Many family caregivers do not automatically identify themselves as caregivers or recognize themselves in the role of a family caregiver for a variety of reasons. As such, States will need to craft plain language questions that are understandable and help individuals see themselves in that role, as appropriate. The questions must be sufficiently detailed for the State to determine eligibility based on an individual's responses. The report “Caregiving in the US” (2025) [ 101 ] ( printed page 33405) includes examples of screening questions used to identify those caring for a child with disabilities or a serious medical condition, and unpaid caregivers of adults. Additional examples are included in a free Caregiver Communications and Marketing Toolkit created by the National Academy of State Health Policy (NASHP) [ 102 ] and the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System (BRFSS) Caregiver Module [ 103 ] used by several States to gather information about family caregivers.