New Citizenship Guidelines for Medicaid Eligibility

National Council Provider Toolkit

• Introduction
• Summary of CMS Guidelines
• Acceptable Documents for Citizenship
• Help with Getting Documents

Questions? Email Chuck Ingoglia at ChuckI@thenationalcouncil.org or call 202.684.7457.

The Centers for Medicare and Medicaid Services (CMS) issued guidelines for states to implement the new requirement that requires documentation of both citizenship and identity for all persons applying for or renewing Medicaid benefits, effective July 1, 2006. The new requirement is mandated by Section 6036 of the Deficit Reduction Act of 2005 (DRA) and is intended to ensure that all Medicaid beneficiaries are citizens.

This toolkit from the National Council for Community Behavioral Healthcare is designed to help direct care staff in behavioral health organizations understand these guidelines and help individual clients in meeting the documentation requirements.

In a guidance letter issued to State Medicaid Directors on June 9, 2006, CMS outlined their initial guidelines for enforcement of this provision (see letter and fact sheet). On July 6, CMS released interim final regulation, exempting senior citizens and people with disabilities who receive Medicare and/or most people who receive Supplemental Security Income (SSI) from the documentation requirement and introducing some additional acceptable forms of documentation. The SSI exemption covers people who live in states that automatically qualify SSI recipients for Medicaid. In the states where Medicaid eligibility is not automatically linked by SSI eligibility - currently CT, HI, IL, IN, MN, MO, NH, ND, OH, OK, VA - the states may access the Social Security Administration's State Data Exchange database to confirm citizenship.

Summary of CMS Guidelines

• The new documentation requirement does not change the eligibility criteria for Medicaid for any group of beneficiaries — instead, it replaces the pre-DRA standard allowing beneficiaries to self-declare their citizenship.
• Senior citizens and individuals with disabilities who also receive Medicare and most people who receive Supplemental Security Income (SSI) will be exempt from the new requirement. The SSI exemption covers people who live in states that automatically qualify SSI recipients for Medicaid. In the states where Medicaid eligibility is not automatically linked by SSI eligibility - currently CT, HI, IL, IN, MN, MO, NH, ND, OH, OK, VA - the states may access the Social Security Administration's State Data Exchange database to confirm citizenship.
• New applicants for Medicaid will not receive benefits until they can present the required evidence.
• All documents must be either originals or copies certified by the issuing agency ? other copies or notarized copies will not be accepted.
• States must maintain copies of the citizenship and identification documents in the case record or electronic database and make these copies available for compliance audits.
• States may use database matches with the State Data Exchange (SDX) for individuals who have already documented their citizenship through information provided when qualifying for other programs or for a driver's license and no longer have access to their documents.
• Individuals who are already enrolled in Medicaid will continue to receive benefits as long as a good faith effort to present evidence of citizenship and identity is shown.
• Providers will continue to be reimbursed for services provided to Medicaid beneficiaries who are making a good faith effort to present evidence of citizenship and identity.
• All beneficiaries will be required to document their citizenship and identity and must do so only once — either as new applicants or upon recertification.
• States are advised to give applicants a "reasonable opportunity" to present documents to establish their citizenship.
• All new applicants and current recipients must prove their identity with a form of photo identification. The only exception listed in the guidance letter is for children under 16.
• A valid US driver's license is currently accepted only as proof of identity ? not citizenship. CMS spells out changes in the state license application process that must be made by the state before a driver's license can be accepted as proof of both identity and citizenship.
• The DRA does not allocate any additional federal funds for state costs associated with administering this new requirement.

Acceptable Documents for Citizenship

CMS describes acceptable documentation of citizenship and identity in four levels or tiers based on reliability. States must first seek documents from the primary list before looking to the second, third, and fourth lists. If an individual is unable to produce a document from the first or primary tier, citizenship can be documented from the second, third, or fourth levels. In rare circumstances, affidavits can be used to document citizenship. Additional types of documents are acceptable for children under age 16.

Tier 1 documents, also referred to as primary documents in the guidance letter, document both citizenship and identity. Examples of Tier 1 documents include:

• US passport
• Certificate of naturalization
• Certificate of citizenship
• In states that do not provide Medicaid to individuals by virtue of their receiving Supplemental Security Income (SSI), states have the option of accepting a state match with the State Data Exchange for SSI recipients

A valid state-issued driver's license can be used to establish both citizenship and identity only if the state issuing the license requires proof of US citizenship before issuing the license or if the state obtains and verifies the applicant's Social Security number as part of the application process. According to CMS, no state currently uses either of these processes. Until a state adopts one or both of these requirements, a driver's license may be used as proof of identity only.

Tier 2 documents establish citizenship only and must be paired with a second document establishing identity. Examples of Tier 2 documents include:

• US birth certificate
• American Indian Card
• Certificate of birth abroad
• Official military record of service listing US birthplace

Final adoption decree listing child's name and US birthplace

States have the option of using a cross match with a state vital statistics agency to document a birth record issued by a state, commonwealth, territory, or local jurisdiction before the person was 5 years of age. An amended birth record document that is amended after 5 years of age is considered fourth level documentation.

Tier 3 documents establish citizenship only and can be used only when documents from Tier 1 and Tier 2 are not available. Documents from Tier 3 must be paired with a second document establishing identity. Examples of Tier 3 documents include:

Tier 4 documents establish citizenship only and are considered evidence of lowest reliability. Documents from Tier 4 must be paired with a second document establishing identity. Tier 4 documentation can be used only in rare circumstances when Tier 1 documents are not available, both Tier 2 or Tier 3 documents do not exist or cannot be obtained within the state's reasonable opportunity period, and the individual claims a US birthplace. Examples of Tier 4 documents include:

• Official hospital record extract stating US place and date of birth
• Life or health insurance record showing a US birthplace
• Federal or state census record showing US citizenship or a US birthplace
• One of the following documents, showing a US birthplace and created at least 5 years before the application for Medicaid: Seneca Indian tribal census; Bureau of Indian Affairs tribal census records of the Navajo Indians; US State Vital Statistics official notification of birth registration; amended US birth record that was amended more than 5 years after the person's birth; statement signed by the physician or midwife who was in attendance at the time of birth
• Medical record created at least five years before the initial application date that indicates a US birthplace institutional admission papers from a nursing home, skilled nursing care facility, or other institution, created at least five years before the initial application date that indicates a US birthplace
• Written affidavit
• US driver's license or state-issued ID card
• School identification card with a photo
• US military card; Native American Tribal document

Written affidavits are to be used in rare circumstances only. The affidavits must be supplied by at least two individuals, one of whom cannot be a relative, who can document their own citizenship and identity for the affidavit to be accepted.

Evidence of identity must accompany Tier 2, 3, or 4 documents in order to satisfactorily document citizenship. Examples of evidence of identity include:

Voter's registration cards and Canadian driver's licenses are not acceptable as evidence of identity.

Children under age 16 are able to document their citizenship and identity using other means. Nursery school or daycare records are also accepted as evidence of identity. Parents may also sign an affidavit as to the identity of their child. If no documents from the four tiers are available for a child, an affidavit stating the date and place of birth may be used. A parent or guardian must sign the affidavit under penalty of perjury.

Help with Getting Documents

Firstgov.gov has created an online guide to "Replacing Your Vital Documents." The guide includes information on obtaining or replacing many types of documents that can be used to prove citizenship and identity, such as birth certificates, driver's licenses, passports, and immigration documents.

The CMS guidance letter does indicate that states should assist new applicants or current recipients who are homeless, mentally impaired, physically incapacitated, or an amnesia victim who cannot provide evidence of citizenship or identity and who lack someone who can act on their behalf. No further information about or on what type of assistance is to be provided for individuals who fall into these categories is given. The National Council suggests you contact your State Medicaid Director for guidance on this issue. To find the contact information for your State Medicaid Director, go to www.nasmd.org/members.htm