Dear Advocates:

June 9, 2006, CMS issued a final version of a Dear State Medicaid Director letter addressing citizenship documentation.  A “Medicaid Fact Sheet” was also issued.  Both of these documents are attached.  These documents will guide state determinations of citizenship pursuant to the newly added 42 USC 1396x (added by section 6036 of the Deficit Reduction Act).  The provision becomes effective on July 1, 2006.  According to CMS, the guidance will be followed by federal regulations that will appear in the Federal Register.

Many of you have monitored this provision, in particular CMS’s previous draft guidance.  As you will see, the final DSMD letter adopts a hierarchical approach to documentation, which is already used by some other public assistance programs.  There are four levels of proof, beginning with a U.S. passport and continuing down to written affidavits, which CMS says should be used “ONLY in rare instances.”  (Emphasis in original).  After level one, all subsequent levels require documentary evidence of citizenship and a second document establishing the person’s identity.  Levels 2-4 can be used only when evidence of citizenship from a higher level is not available.  Among others, the following documentation is recognized:

 Final adoption decree showing a child’s name and US place of birth (Level 2).  An exception process is included for instances where an adoption is not finalized and the state in which the child was born will not release a birth certification prior to final adoption.

 Life or health or other insurance record showing a US place of birth, created at least 5 years before the initial application date (Level 3)

 Federal or State census record showing US citizenship or a US place of birth (Level 4)

 Institutional admission papers from an institutional placement, created at least 5 years before the initial application date (Level 4)

 Medical (clinic, doctor, hospital) record, indicating US place or birth, created at least 5 years before the initial application date (Level 4)

 Written affidavit by at least two individuals, of whom one is not related to the applicant/recipient and who have personal knowledge of the events establishing the individual’s citizenship.  (NOTE:  the previous draft version of this letter had required only one individual’s attestation) (Level 4)

If a person “in good faith” attempts to provide documentation but cannot, then the state may use matches with other agencies to assist applicants/recipients.

If an applicant is homeless, an amnesia victim, mentally impaired or physically incapacitated and lacks someone who can act for them, and cannot provide evidence of citizenship or identity, the State should assist the individual.

The state’s administrative requirements for timely decision-making, as framed by the federal regulations, 42 CFR 435.950 and 435.911, will continue to apply.

Existing practices in New York and New Hampshire are mentioned with favor. 

 Finally, although the declared basis for the approach is questionable, CMS is viewing this as a “cooperation” requirement that can result in denial or termination if the individual does not provide required information.