• Mission & Governance
• Services Overview
• How to Get Involved
• Standing Committees
• NCSL Foundation

• Issue Areas: A-Z
• State-Federal Relations
• NCSL Standing Committees
• News from D.C. and the States

• About State Legislatures
• Elections, Campaigns & Redistricting
• NCSL's StateConnect Directory
• Web Sites

• Online Guide to NCSL Services
• Staff Sections and Networks
• Meetings & Professional Development
• Staff Directories

• Meetings Calendar
• Online Registration
• Meetings Home Page
• Legislative Summit

• Bookstore
• State Legislatures Magazine
• NCSL's StateConnect Directory

CMS Guidance Regarding Citizenship Documentation Requirements for Medicaid Applicants

The passage of the Deficit Reduction Act of 2005 (DRA) imposed new requirements on states in verifying citizenship or nationality of Medicaid recipients. Effective July 1, 2006, Section 6036  will prohibit states from receiving federal reimbursement for medical assistance provided under the Medicaid program to any individual who has not provided satisfactory documentary evidence of their citizenship or nationality. The documentation requirements would not apply to an immigrant who is (1) eligible for Medicaid and is entitled to or enrolled for Medicare benefits, (2) eligible for Medicaid on the basis of receiving Supplemental Security Income benefits or (3) eligible for Medicaid as specified by the secretary under which satisfactory documentary evidence of citizenship or nationality had been previously presented. 

March 20, 2007, Leslie V. Norwalk, Acting Administrator of the Centers for Medicare & Medicaid Services (CMS), announced that all babies born in the United States whose deliveries are covered by Medicaid may remain eligible under certain circumstances for Medicaid up to a year after birth. 

Section 1902(e)(4) of the Social Security Act ("the Act") provides that a child born to a mother receiving Medicaid will automatically be eligible for Medicaid for one full year, if certain conditions are met.  As a result of this "deemed" status, the States do not make a new eligibility determination for the infant at the time of birth; rather, eligibility is continued under the mother's status for the first year.  Under CMS' July 2006 interim final rule implementing Section 1903(x) of the Act, this "deeming" process does not extend to the newborns of non-citizen mothers who are not ordinarily eligible for Medicaid but receive emergency Medicaid services for labor and delivery of a child.   

CMS officials plan to modify this policy in an interim final rule that will be issued shortly.  All babies who are born in the United States whose deliveries are covered by Medicaid will be put on an equal footing -- any newborn whose mother files an application and is determined eligible for emergency Medicaid for the delivery could be deemed eligible for Medicaid for the first year of life.  Documentation of eligibility would be required at redetermination in the same manner as for all deemed newborn.

The Center for Medicare and Medicaid Services has developed a toolkit for state and local government officials to provide information they need to aid constituents in understanding the process and providing the documentation necessary to show they are U.S. citizens to be able to enroll in Medicaid.

Documentation of Citizenship for Medicaid: Toolkit for State and Local Government Officials

CMS Final Rule

• Approved the use of the Department of Homeland Security’s (DHS) Systematic Alien Verification for Entitlements (SAVE) database for purposes of verifying citizenship for naturalized citizens, subject to DHS authorization.
• Expanded the list of appropriate documents to document citizenship by including religious records recorded in the U.S. within three months of birth and early school records as third level evidence of citizenship. This policy is consistent with the Social SecurityAdministration’s policy for issuing social security numbers.
• Approved the Roll of Alaska Natives as fourth level evidence of citizenship.
• Permitted naturalized citizens to utilize the affidavit process.
• Approved the use of three or more corroborating documents such as marriage licenses, divorce decrees, high school diplomas and employer ID cards to document the identity of an individual.
• Approved the use of identity affidavits for children up to 16 years of age (18 in limited circumstances) and disabled individuals in residential care facilities.
• Approved the use of clinic, doctor and hospital records to verify a child’s identity.
• Revised the language used to describe birth records to be consistent with the National Association for Public Health Statistics and Information Standards (NAPHSIS). This entails replacing the words “issued” with “recorded” and “amended” with “delayed.” This language reflects CMS’ original intent of accepting birth records that were recorded with vital statistics within five years of birth as secondary evidence of citizenship and birth records that were recorded with vital statistics after five years of birth (a delayed birth record) as fourth level evidence of citizenship.
• Permitted states to recognize all newborn children of women who have applied for, have been determined eligible and who are receiving Medicaid on the date of the child’s birth as deemed newborns so long as the mother remains eligible and the child remains a member of the mother’s household regardless of the mother’s immigration status. Documentation of citizenship and identity would be required at the first period of redetermination (up to one year). This would include children whose births are covered by emergency Medicaid. Women may qualify for emergency Medicaid only if they submit a full application and are determined to meet all other Medicaid requirements.

Final Rule (Published July 13, 2007)

Fact Sheet

Citizenship Documentation Requirements Required By the deficit reduction act (DRA)
Acceptable primary documentation for identification and citizenship:	A U.S. Passport A Certificate of Naturalization (DHS Forms N-550 or N-570). A Certificate of U.S. Citizenship (DHS Forms N-560 or N-561).
Acceptable secondary documentation to verify proof of citizenship (an identity document is also required):	A U.S. birth certificate.  A Certification of birth issued by the Department of State (Form DS-1350).   A Report of Birth Abroad of a U.S. Citizen (Form FS-240).   A Certification of Birth Abroad (FS-545).   A U.S. Citizen I.D. card (DHS Form I-197).   An American Indian Card issued by the Department of Homeland Security with the classification code “KIC.” (Issued by DHS to identify U.S. citizen members of the Texas Band of Kickapoos living near the U.S./Mexican border).   A Northern Mariana Identification Card. (Issued by the INS to a collectively naturalized citizen of the United States who was born in the Northern Mariana Islands before November 4, 1986.).  Evidence of civil service employment by the U.S. government before June 1976.   An official military record of service showing a U.S. place of birth.  A verification with the Department of Homeland Security’s Systematic Alien Verification for Entitlements (SAVE) database. Evidence of meeting the automatic criteria for U.S. citizenship outlined in the Child Citizenship Act of 2000.
Acceptable third level documentation to verify proof of citizenship:	Extract of a hospital record on hospital letterhead established at the time of the person’s birth that was created 5 years before the initial application date and showing a U.S. place of birth (for children, record must have been created near the time of birth).   Life or health or other insurance record, which shows a U.S. place of birth that was created at least 5 years before the initial application date (or near time of birth for children).   Religious record recorded in the U.S. within 3 months of birth showing the birth occurred in the U.S. and showing either the date of the birth or the individual’s age at the time the record was made. The record must be an official record recorded with the religious organization. (Entries in a family bible are not considered religious records.) Early school record showing a U.S. place of birth. The school record must show the name of the child, the date of admission to the school, the date of birth, a U.S. place of birth, and the name(s) and place(s) of birth of the applicant’s parents.
Acceptable fourth level documentation to verify proof of citizenship:	Federal or state census record showing U.S. citizenship or a U.S. place of birth.  Institutional admission papers from a nursing home, skilled nursing care facility or other institution and was created at least 5 years before the initial application date and indicates a U.S. place of birth.  Medical (clinic, doctor, or hospital) record and was created at least 5 years before the initial application date and indicates a U.S. place of birth (for children under 5, record is created near time of birth).   Other document that shows a U.S. place of birth and that was created at least five years before the application for Medicaid (or for children under 16 near the time of birth). These documents are a Seneca Indian tribal census record, a Bureau of Indian Affairs tribal census records of the Navajo Indians, a U.S. State Vital Statistics official notification of birth registration, a delayed U.S. public birth record that was recorded more than 5 years after the person’s birth, a statement signed by the physician or midwife who was in attendance at the time of birth, and the Bureau of Indian Affairs Roll of Alaska Natives. Written affidavit.--Written affidavits may be used as fourth-level evidence only in rare circumstances when the state is unable to secure evidence of citizenship from another, higher-level listing. The affidavits must be supplied by the applicant or recipient and at least two additional individuals, one of whom is not related to the applicant or recipient. Each of the two additional individuals must attest to having personal knowledge of the event(s) establishing the applicant’s or recipient’s claim of citizenship. The individuals providing supporting affidavits must be able to prove their own citizenship and identity for the affidavit to be accepted. The applicant /recipient also submits an affidavit explaining why other documentary evidence is not available. Affidavits are signed under penalty of perjury, but need not be notarized.

Acceptable documentation to verify proof of identity:

• A current state driver’s license or State identity document bearing either the individual’s picture or containing other identifying information, such as name, age, sex, race, height, weight or eye color.
• School identification card with a photograph of the individual. 
• U.S. military card or draft record. 
• Identification card issued by the Federal, State, or local government with the same information included on driver's licenses. 
• Military dependent's identification card. 
• Certificate of Indian Blood, or other U.S. American Indian/Alaska Native tribal document. 
• U.S. Coast Guard Merchant Mariner card. 
• A cross-match with a Federal or State governmental, public assistance, law enforcement, or corrections agency’s data system. 
• At State option, 3 or more corroborating documents such as marriage licenses, divorce decrees, high school diplomas and employer ID cards to verify the identity of an individual (only to be used if applicant submitted 2^nd or 3^rd tier – not 4^th tier – citizenship documentation).

Children who are under age 16 may have their identity documented using other means

• School record including report card, daycare or nursery school record. 
• Clinic, doctor or hospital record. 
• Affidavit signed under penalty of perjury by a parent, guardian or caretaker relative attesting to the child’s identity, if other documents are unavailable. Identity affidavit should not be used if citizenship affidavit was used. Affidavits need not be notarized. (Identity affidavits may be used for children under age 18 in limited circumstances.)

Disabled individuals in residential care facilities may have their identity attested to by the facility director or administrator when the individual does not have or cannot get any document on the preceding lists. Again, the affidavit is signed under penalty of perjury, but need not be notarized.

Reasonable Opportunity

At the time of application or redetermination, the state must give an applicant or recipient a “reasonable opportunity” to present documents establishing U.S. citizenship or nationality and identity. The guidance advises:

• An individual who is already enrolled in Medicaid will remain eligible if he/she continuously shows a good faith effort to present satisfactory evidence of citizenship and identity.
• Applicants for Medicaid should not be made eligible until they have presented the required evidence. 
• If the applicant or recipient tries in good faith to present satisfactory documentation, but is unable because the documents are not available, the state should assist the individual in securing these documents. 
• If the applicant or recipient cannot obtain the necessary documents and needs assistance (i.e., is homeless, mentally impaired, or physically incapacitated), and lacks someone who can act on their behalf, then the state should assist the applicant or recipient to document U.S. citizenship and identity.

Copies of the law, the State Medicaid Director Letter that includes detailed information regarding this statute and the specific documents that are recognized as satisfactory documentary evidence of citizenship and identity and an associated Medicaid Fact Sheet are linked below:

Section 6036 http://www.ncsl.org/statefed/health/ReconDocs0206.htm

Link to parent document

For further information, please call NCSL staff Joy Johnson Wilson, Health Policy Director at 202-624-8689 or Rachel Morgan RN, BSN, Senior Health Policy Specialist at 202-624-3569.