The MassHealth noncustodial parent form, often called the NCP form, is what the custodial parent fills out when a child on a MassHealth application has another parent living outside the household. It collects identifying, employment, and insurance details about that absent parent so the Department of Revenue’s Child Support Enforcement Division can decide whether the non-custodial parent should be providing health coverage or contributing to the child’s medical costs. You can send the completed form through Adobe Sign on mass.gov, by fax to (857) 323-8300, or by mail to the Health Insurance Processing Center, PO Box 4405, Taunton, MA 02780.
Who Has to Fill It Out
The form is for the custodial parent or legal guardian listed on the health care coverage application, not the non-custodial parent. If you are applying for MassHealth for a child whose other parent lives elsewhere, you will be asked to complete and sign it.
Under 130 CMR 517.009, cooperating with MassHealth and the Department of Revenue is a condition of your own eligibility. Cooperation includes helping establish paternity if the child was born outside of marriage, providing what you know about the non-custodial parent, and helping the agency pursue any third party legally obligated to pay for the child’s care.1Mass.gov. 130 CMR 517: MassHealth Universal Eligibility Requirements If giving this information could put you or your child in danger, you can claim a good cause exception on the form itself.
What Information to Gather Before You Start
Most fields include an “I do not know” checkbox, so missing details will not stop you from submitting. The more you can provide, the faster the process moves.2MassHealth. Noncustodial Parent Form
About the Non-Custodial Parent
You will be asked for the parent’s full legal name, relationship to the child, gender, date of birth, Social Security number, driver’s license number, current or last known address and phone number, and employer name and address. Employment details matter because MassHealth and the Department of Revenue use them to determine whether the parent has access to employer-sponsored coverage that could be extended to the child.
Insurance
The form asks whether the non-custodial parent currently carries insurance that covers dependents. If yes, or if you are unsure, provide the policyholder’s name, insurance company, policy number, and group number. Check “I do not know” for any detail you cannot provide.2MassHealth. Noncustodial Parent Form
Court Orders
Two questions ask whether a court has already ordered the non-custodial parent to provide health insurance, one for the child and one for you. If an order exists, you will enter where and when it was issued. There is no docket or case number field.2MassHealth. Noncustodial Parent Form
The Child
Confirm the child’s legal name and date of birth as they appear on official records. If more than one child shares the same non-custodial parent, you can list them all on one form.
Claiming Good Cause
If cooperating would put you or your child at risk, check the good cause box on the form. Under 130 CMR 517.010, good cause includes serious physical or emotional harm to the child, to you, or to a relative the child lives with; conception as a result of forcible rape or incest; a pending adoption proceeding in court; and active adoption counseling by a public agency or licensed facility where discussions have not lasted longer than three months.3Legal Information Institute. 130 CMR 517.010 – Waiver of Cooperation for Good Cause
After you check the box, MassHealth staff review your claim and may ask for supporting documentation such as police reports, protective orders, or statements from social workers or domestic violence counselors. Your benefits should not be terminated for non-cooperation while the claim is pending.
How to Submit the Form
You have three options. Electronic submission through Adobe Sign is the fastest and gives you an automatic confirmation.
Adobe Sign
MassHealth hosts the form through Adobe Sign on mass.gov. Download the free Adobe Reader if you do not have it, open the Noncustodial Parent Form link on the MassHealth NCP form page, and fill in the required fields. You must enter a valid email address so Adobe can send you a signing link; MassHealth receives the address but does not keep it in your records. Check your email for the Adobe Sign link and complete the signature. The form is not sent to MassHealth until you sign. Adobe then emails you a PDF copy for your records.4Mass.gov. Noncustodial Parent (NCP) Form
Fax or Mail
If you prefer to print and complete the form by hand, fax it to (857) 323-8300 or mail it to the Health Insurance Processing Center, PO Box 4405, Taunton, MA 02780.2MassHealth. Noncustodial Parent Form Keep your fax confirmation page, or save a copy of the completed form before mailing. MassHealth does not provide a tracking number for mailed documents, so your own records are the only proof of timely submission.
What Happens After You Send It In
MassHealth forwards your information to the Department of Revenue’s Child Support Enforcement Division, which uses it to locate the non-custodial parent and determine whether that parent can provide coverage, either through an employer plan or through a medical support order.
If the non-custodial parent has employer-sponsored insurance that covers dependents, the Department of Revenue can issue a National Medical Support Notice to the employer. Under federal rules, the employer has 20 business days to respond and, if the employee is eligible, begin enrollment.5Office of the Attorney General for the District of Columbia. National Medical Support Notice The division may contact you for a follow-up interview to clarify what you reported. MassHealth will notify you once the cooperation requirement is satisfied and your application can move forward.
If You Do Not Cooperate
Your child’s MassHealth coverage is not at risk. MassHealth will not deny or terminate the child’s benefits because you did not complete the NCP process.2MassHealth. Noncustodial Parent Form Your own coverage is different. Under 130 CMR 517.009, MassHealth will deny an applicant who does not attest to willingness to cooperate and will terminate a member who refuses to cooperate, unless the member shows good cause.1Mass.gov. 130 CMR 517: MassHealth Universal Eligibility Requirements In practice, you can lose your own MassHealth coverage while your children keep theirs. If you decide to cooperate later, you can reapply or call to resolve the issue. For questions about the form or the cooperation requirement, call the MassHealth Customer Service Center at (800) 841-2900.6Mass.gov. MassHealth