DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-26-12
Baltimore, Maryland 21244-1850
Center for Medicaid and State Operations
December 28, 2009
SHO #:09-016
CHIPRA #: 11
RE: Citizenship Documentation Requirement
Dear State Health Official:
This letter is one of a series that provides guidance on the implementation of the Children’s
Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Pub. L. 111-3. Specifically,
this letter addresses the provisions of section 211 regarding the citizenship documentation
requirement for Medicaid and the Children’s Health Insurance Program (CHIP). The Deficit
Reduction Act of 2005 (DRA), Pub. L. 109-171, amended sections 1902 and 1903 of the Social
Security Act (the Act), to require Medicaid applicants who declare to be a U.S. citizen or
national to present satisfactory documentary evidence of citizenship prior to enrollment in
Medicaid. Section 211 of CHIPRA revises several of these requirements, and, effective
January 1, 2010, applies these requirements to CHIP and permits States to verify citizenship for
individuals newly enrolled using a data file match with the Social Security Administration
(SSA). This letter provides an overview and guidance on the changes made by section 211 of
CHIPRA.
Background
Prior to enactment of the DRA, Medicaid applicants could attest under penalty of perjury that
they were U.S. citizens or nationals. States could require documentary evidence of citizenship or
nationality but were not required to do so. Effective July 1, 2006, the DRA created a new
section 1903(x) of the Act which requires States to obtain satisfactory documentary evidence of
citizenship or nationality when enrolling individuals in Medicaid or at the first point of eligibility
redetermination. Certain populations, including most individuals receiving Medicare, disability
insurance benefits, supplemental security income benefits, children in foster care, and children
receiving foster care or adoption assistance are exempt from these requirements. Federal
implementing regulations at 42 CFR 435.406 and 435.407 outline the groups of individuals that
are subject to citizenship documentation requirements and describes the criteria for documents
that can be provided to confirm citizenship.
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CHIPRA Changes Related to Documentation of Citizenship in Medicaid and CHIP
Section 211 of CHIPRA includes several provisions modifying the Medicaid requirement for
documentation of citizenship, including a new option to assist States in meeting this requirement:
• Eligible individuals who declare to be U.S. citizens or nationals must be provided a
reasonable opportunity to present satisfactory documentation of citizenship or nationality
and must be enrolled in coverage pending the reasonable opportunity to document that
claim;
• Tribal enrollment or membership documents issued from a federally recognized Tribe
must be accepted as verification of citizenship; no additional identity documents are
required.
• Children who are initially eligible for Medicaid or CHIP as “deemed newborns” are
considered to have provided satisfactory documentation of citizenship and may not be
required to submit further documentation at subsequent eligibility determinations or re-
determinations;
• A new State option, available beginning January 1, 2010, allows verification of a
declaration of citizenship for individuals newly enrolled in CHIP or Medicaid using a
data match with SSA to confirm the consistency of a declaration of citizenship with SSA
records, in lieu of the presentation of citizenship documentation; and
• The citizenship verification requirements described above will apply to CHIP beginning
January 1, 2010.
Additional policy and regulatory guidance will be forthcoming on this issue and the Centers for
Medicare & Medicaid Services (CMS) will continue to work with States to help them implement
these provisions in a manner that is consistent with the statute.
Reasonable Opportunity to Present Satisfactory Documentary Proof of Citizenship
CHIPRA amends section 1903(x) of the Act requiring States to provide an individual who
declares U.S. citizenship or nationality, under penalty of perjury, with at least the same
reasonable opportunity to present evidence, as specified in sections 1137(d)(4)(A)(i) and (ii) of
the Act, as individuals who are required to submit evidence indicating a satisfactory immigration
status. States have flexibility to define what constitutes a reasonable opportunity period, but may
not apply a standard to citizens and nationals that is more restrictive than such standard applied
to immigrants.
Under this new provision, the State must allow an individual to declare citizenship and must not
deny, delay, reduce, or terminate Medicaid or CHIP eligibility while the documentation is
gathered during a reasonable opportunity period. Once an individual has declared that he or she
is a U.S. citizen or national and has provided all other information that the State needs to
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determine eligibility, the State must make a decision on whether the applicant is eligible. If the
State determines that the individual is otherwise eligible, it must provide benefits while the
individual secures the documents needed to satisfy the citizenship documentation requirement.
The reasonable opportunity period does not affect the applicability of the timeliness standards at
42 CFR 435.911.
If an individual has not provided satisfactory documentation of citizenship by the end of the
reasonable opportunity period, and any extension period, States may terminate that individual’s
eligibility for Medicaid or CHIP benefits in accordance with Medicaid rules at 42 CFR 435.919
and 42 CFR 431 Subpart E (regarding timely notice and opportunity for a fair hearing). Federal
financial participation (FFP) will be provided for claims that occur during the reasonable
opportunity period, even if eligibility is ultimately terminated due to lack of documentation.
This provision took effect on July 1, 2006, as if included in the DRA. (See Page 8 for further
discussion.)
Acceptance of Tribal Documents for Proof of Citizenship
Section 211 of CHIPRA also clarified certain provisions of the DRA related to acceptance of
documents issued by a federally recognized Indian Tribe for documentation of citizenship or
nationality. Section 1903(x)(3)(B) of the Act, as amended by CHIPRA, specifies that a
document issued by a federally recognized Indian Tribe evidencing membership, enrollment in,
or affiliation with such Tribe is satisfactory documentary evidence of an individual’s U.S.
citizenship or nationality. The document must identify the Federally recognized Indian Tribe
which issued it, identify the individual by name, and confirm the individual’s membership,
enrollment in, or affiliation with that Tribe. Some examples include Tribal enrollment and
membership cards, a certificate of degree of Indian blood issued by the Bureau of Indian Affairs,
a Tribal census document, or a document issued by a Tribe indicating an individual’s affiliation
with the Tribe. These documents are examples of documents that may be used, but do not
constitute an all-inclusive list of such documents. Tribal documents are now considered to be as
reliable as a passport and are treated as “Tier 1” documents under Federal regulations at 42 CFR
435.407. Additional identity documentation is not required to be presented.
CMS will update current federal regulations authorizing the presentation of other forms of
documentation, including Tribal documentation that may be used to satisfy the citizenship
documentation requirements. During the period that begins on July 1, 2006, and ends on the
effective date of the final regulations (forthcoming), an individual who is a member of a
federally recognized Indian Tribe who presents a Tribal document as described above is deemed
to have presented satisfactory evidence of citizenship.
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It is important for States to recognize that Tribes are individual independent governments that
may not have uniform methods of documenting membership, enrollment, or affiliation with a
particular Tribe. CMS encourages States to contact Tribes located in their States for assistance
in identifying documents used by those Tribes. CMS will provide technical assistance to States
and Tribes to assist in the implementation of this provision.
With respect to federally-recognized Indian Tribes located within States having an international
border and whose membership includes individuals who are not U.S. citizens, CHIPRA requires
that the Secretary, after consultation with the Tribe, issue regulations regarding presentation of
documentation sufficient to establish the citizenship of Tribal members who have declared they
are citizens of the U.S.
The CMS has consulted with the Tribes concerning the implementation of this provision.
Specifically, the Tribal Affairs Group and the Center for Medicaid and State Operations within
CMS jointly hosted an All Tribes call on June 19, 2009 to consult on this and other provisions in
CHIPRA. Two face-to-face consultation meetings were held in Denver on July 8, 2009, and July
10, 2009, to solicit advice and input from federally-recognized Tribes, Indian health providers,
and Urban Indian Organizations on these provisions. In addition, CMS obtained the advice and
input regarding implementation of section 211 from the CMS Tribal Technical Advisory Group
at its July 30-31, 2009 meetingand no alternative types of Tribal documents were identified
beyond the Tribal documents mentioned above.
These provisions took effect on July 1, 2006, as if included in the DRA. (See Page 8 for further
discussion.)
Children Born in the U.S. to Mothers Eligible for Medicaid or CHIP
Section 1903(x) of the Act was also amended to provide that individuals who are initially
eligible for Medicaid or CHIP as “deemed newborns” are considered to have provided
satisfactory documentation of citizenship and identity (by virtue of being born in the United
States) and will not be required to further document citizenship or nationality at any subsequent
Medicaid or CHIP eligibility determination or redetermination. Previously, under regulations
promulgated pursuant to the DRA, documentation of citizenship was required at the first
redetermination of Medicaid eligibility after the deemed newborn eligibility period ends, when
the child turns 1 year old. CHIPRA repeals this regulatory requirement. CMS provided general
guidance on the eligibility of deemed newborns in its August 31, 2009, letter to State Health
Officials (SHO 09-009), available at
http://www.cms.hhs.gov/smdl/downloads/SHO083109b.pdf.
This provision took effect for Medicaid on July 1, 2006, as if included in the DRA. (See page 8
for further discussion.)
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New State Option in Lieu of Requiring Documentary Evidence of Citizenship or
Nationality
Effective January 1, 2010, section 211 of CHIPRA amends section 1902(a)(46) of the Act by
adding subparagraph (B) that provides a new optional State process at section 1902(ee) for
documenting the citizenship or nationality for those Medicaid or CHIP applicants declaring to be
U.S. citizens or nationals. This process may be used in lieu of requiring the applicant to present
satisfactory documentary evidence of citizenship or nationality as specified in 42 CFR 435.407.
States that do not elect this option must continue to document citizenship and nationality in
accordance with Federal regulations at 42 CFR 435.406 and 407 and policy requirements
included elsewhere in this letter.
In accordance with a new section 1902(ee) of the Act, a State may submit to SSA the applicant’s
name, Social Security Number (SSN), and date of birth (DOB) for comparison with information
that SSA has on record for the individual. SSA will compare an individual’s name, SSN, and
citizenship declaration provided by the State with data in its Master File of SSN Holders
(Numident). States are expected to move forward with enrolling individuals during this
verification period and eligibility may not be delayed, denied, or terminated pending the
completion of the data matching process.
SSA Operational Implementation of the New Option
To support this exchange of information, SSA will use the existing electronic batch data
exchange, known as the State Verification and Exchange System (SVES), currently in use for all
States with SSA. SVES operates via a network known as the File Transfer Management System.
States currently send requests for SSN verification to SSA on a daily basis, and SSA’s responses
are sent to States the next day (referred to as an “overnight batch”).
If a State elects the CHIPRA option for an SSA file match, the authority for entering into this
data exchange will be documented by a revised Computer Matching and Privacy Protection Act
(CMPPA) agreement and Information Exchange agreement that States will need to sign with
SSA no later than December 31, 2009, if they wish to use this option beginning January 1, 2010.
States that are currently operating separate CHIP eligibility programs will need to implement a
process to connect to the State Medicaid agency to enable the processing of verification of
citizenship for new applicants through SVES for CHIP. As explained below, States may receive
enhanced Federal matching payments for the design, development and installation of systems
necessary to implement this electronic data matching option.
In collaboration with CMS, SSA has been working closely with the States by incorporating
CHIP into the CMPPA model agreements and has provided test cases for use by the States.
CMS and SSA will continue to work closely with the States to ensure a smooth transition to this
new system.
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Operation of the Data Exchange
For the citizenship verification inquiry, States will submit an SVES request that contains a
special indicator of “Medicaid/CHIP” in the input field. This request will provide the States with
SSA’s standard response as well as a specific response with respect to whether SSA can confirm
the individual’s attestation of U.S. citizenship or nationality. SSA will match each individual’s
information provided by the State with SSA’s records. SSA will provide a response to every
query submitted by the State. Responses will indicate a confirmation of the data submitted by
the State is consistent with SSA records, a response that indicates an inconsistency with SSA
records, or a response that indicates that there is no match with SSA records. The State will
receive a reply for each record that SSA is unable to process due to missing or invalid data.
A response from SSA that confirms that the data submitted by the State is consistent with SSA
data, including citizenship or nationality, meets the citizenship verification requirements. No
further action is required for the State or individual and no additional documentation of either
citizenship or identity is required.
Resolution of Data Inconsistencies and Continued Enrollment
An inconsistency between the data submitted by the States and SSA’s data means that the State’s
submitted information (individual’s name, SSN, DOB, or citizenship declaration) is not a match
with the information in SSA’s Numident files. In these instances, SSA does not provide the
State a confirmation that citizenship is substantiated. The State must correct its information and
resubmit the request in order to obtain citizenship substantiation for the individual.
If the State receives notice from SSA that the individual’s name, SSN, DOB, or declaration of
citizenship or nationality is inconsistent with information in SSA’s records, or if no match is
found by SSA, the State must first make a reasonable effort to identify and resolve the cause of
this result (e.g., a typographical or other clerical error) that may have originated with the State
and can be resolved by research of the State’s records. If an error is identified, the State must
correct its information and resubmit the request in order to confirm the citizenship verification
for the individual. If the inconsistency is not resolved by such efforts, the State shall notify the
individual and provide the individual with 90 days from the date that the notice is received either
to provide satisfactory documentation of citizenship or nationality to the State as described at 42
CFR 435.406 and 435.407, or to resolve the inconsistency with SSA’s information if the issue
causing the discrepancy is related to the SSN, name, or date of birth. The individual remains
enrolled in Medicaid or CHIP during this effort.
After 90 days, if the inconsistency has not been resolved or documentary evidence of citizenship
or nationality has not been provided, the State must disenroll the individual with timely and
adequate notice within 30 days. The individual may appeal the disenrollment and request a fair
hearing in accordance with standard notice and fair hearing procedures.
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Reporting Requirements
A State electing this SSN matching option must report to CMS the percentage of inconsistent
submissions as compared to total submissions to SSA each month. For the purpose of this
reporting, a submission is counted as inconsistent if the State could not resolve the inconsistency
with SSA’s records, the individual did not successfully resolve the inconsistency or provide
satisfactory documentation of citizenship status after a reasonable opportunity, and CHIP or
Medicaid paid for an item or service received by the individual. CMS will issue additional
guidance specifying the timeframe and format for this information.
As required by the statute, if for any Federal fiscal year (FFY), the State’s average monthly rate
of inconsistencies exceeds 3 percent, the State must develop and adopt a corrective action plan to
review its procedures for verifying the identities of Medicaid and CHIP applicants, and must
identify and implement changes in its procedures to improve the accuracy. Also, the State must
reimburse CMS a certain amount of Medicaid or CHIP payments for the FFY for individuals
who provided inconsistent information, based on the number of individuals with inconsistent
information in excess of 3 percent as a percentage of the total number of individuals with
inconsistent information. The Secretary of Health and Human Services (HHS) may waive, in
certain limited cases, all or part of the payment if the State is unable to reach the allowable
3 percent of inconsistencies despite a good faith effort. CMS will issue separate guidance on the
criteria for such waivers.
Enhanced FFP for File Match System with SSA
A State may claim FFP for 90 percent of the sums expended during a calendar quarter that are
attributable to the design, development, or installation of a mechanized verification and
information retrieval system that the Secretary of HHS determines is necessary to implement this
option for a file match with SSA. The 90 percent match will also be available for implementing
a connection with a separate CHIP eligibility program to enable application of this process to
CHIP. The CHIP administrative expenditures cap does not apply to expenditures necessary for
the State to implement this provision. In addition, a State may claim FFP for 75 percent of the
sums expended during a calendar quarter that are attributable to operation of these systems.
Application of Citizenship Documentation Requirements to CHIP
Effective January 1, 2010, section 2105(c) of the Act is amended to apply to separate CHIP
programs the requirement to provide verification of citizenship or nationality as a condition of
enrollment. (The requirement currently applies to CHIP-funded Medicaid expansion programs,
so this provision aligns the requirements for both programs.)
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Separate CHIP programs are given the option to verify citizenship of new CHIP applicants using
a file match with SSA in lieu of obtaining documentary evidence of citizenship or nationality.
However, as stated above, SSA will not establish separate connections to separate CHIP
programs. Those programs must establish a connection through the State’s current Medicaid
SVES data exchange.
Restoration of Medicaid Eligibility
As noted above, the effective date of the CHIPRA provisions related to reasonable opportunity,
Tribal documentation, and citizenship of deemed newborns is July 1, 2006, the effective date of
the DRA. This retroactive effective date means that an individual previously determined
ineligible for Medicaid, including under a section 1115 waiver program, during the period of
July 1, 2006, through October 1, 2009, must be granted eligibility 1) if the individual was
determined ineligible solely due to the requirements for documentation of citizenship or
nationality in effect at the time the ineligibility determination was made; and 2) the individual
would be eligible by applying the provisions of section 1903(x) that were amended by section
211(b) of CHIPRA (i.e., Tribal documents, reasonable opportunity period, citizenship of deemed
newborns). In such case, the State must grant or restore the eligibility effective with the date the
individual would have been eligible were these CHIPRA provisions in effect at the time of the
determination of ineligibility.
In addition, CHIPRA provides States with the option to “deem” individuals to be eligible
retroactively to the date the individual would have been eligible if the States can identify
individuals meeting criteria (1) and (2) discussed above. Under this deeming option, the State
would not need to perform a new eligibility determination, but rather, would be able to “deem”
the individual as retroactively eligible and restore eligibility accordingly. CMS will work with
States interested in pursuing this option.
Contact Information
If you have questions regarding this guidance, please send an email to
[email protected] or contact Ms. Victoria Wachino, Director, Family and
Children’s Health Programs Group, who may be reached at (410) 786-5647.
Sincerely,
/s/
Cindy Mann
Director
Page 9 – State Health Official
cc:
CMS Regional Administrators
CMS Associate Regional Administrators
Division of Medicaid and Children’s Health
Ann C. Kohler
NASMD Executive Director
American Public Human Services Association
Joy Wilson
Director, Health Committee
National Conference of State Legislatures
Matt Salo
Director of Health Legislation
National Governors Association
Debra Miller
Director for Health Policy
Council of State Governments
Christine Evans, M.P.H.
Director, Government Relations
Association of State and Territorial Health Officials
Alan R. Weil, J.D., M.P.P.
Executive Director
National Academy for State Health Policy
