Department of Health and Human Services

OFFICE OF 

INSPECTOR GENERAL 

S -D U.S. 

ELF ECLARATION OF 
C M
ITIZENSHIP FOR  EDICAID

Daniel R. Levinson

Inspector General 

July 2005

OEI-02-03-00190
 Office of Inspector General 

http://oig.hhs.gov 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, 
as amended, is to protect the integrity of the Department of Health and Human Services 
(HHS) programs, as well as the health and welfare of beneficiaries served by those 
programs. This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others. 
Audits examine the performance of HHS programs and/or its grantees and contractors 
in carrying out their respective responsibilities and are intended to provide independent 
assessments of HHS programs and operations in order to reduce waste, abuse, and 
mismanagement and to promote economy and efficiency throughout the department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management 
and program evaluations (called inspections) that focus on issues of concern to the 
department, the Congress, and the public. The findings and recommendations contained 
in the inspections reports generate rapid, accurate, and up-to-date information on the 
efficiency, vulnerability, and effectiveness of departmental programs.  The OEI also 
oversees State Medicaid fraud control units, which investigate and prosecute fraud and 
patient abuse in the Medicaid program. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 
and of unjust enrichment by providers. The investigative efforts of OI lead to criminal 
convictions, administrative sanctions, or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to 
the OIG, rendering advice and opinions on HHS programs and operations and providing 
all legal support in OIG's internal operations. The OCIG imposes program exclusions 
and civil monetary penalties on health care providers and litigates those actions within 
the department. The OCIG also represents OIG in the global settlement of cases arising 
under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops compliance program guidances, renders advisory opinions on OIG sanctions to 
the health care community, and issues fraud alerts and other industry guidance.  E X E C U T I V E   S U M M A R Y
  E X E C U T I V E   S U M M A R Y  

OBJECTIVES 
Our objectives were to determine the extent to which States allow 
self-declaration of U.S. citizenship for Medicaid and related programs 
and to identify potential vulnerabilities, if any, associated with 
quality control activities and evidence used to document citizenship.   
BACKGROUND 
The Personal Responsibility and Work Opportunity Reconciliation Act 
of 1996 restricts eligibility for Medicaid to U.S. citizens, nationals of 
the United States, or qualified aliens.  Since 1986, verification of U.S. 
citizenship for purposes of Medicaid eligibility has been governed by 
section 1137(d) of the Social Security Act (the Act).  The Act requires 
a declaration in writing, under penalty of perjury . . . stating whether 
the individual is a citizen or national of the United States.  Pursuant 
to the Act, the Centers for Medicare & Medicaid Services (CMS) 
allows, but does not require, States to accept self-declaration of 
citizenship without requiring submission of additional documentary 
evidence.  In September 2002, CMS planned to issue a final rule that 
would permit States to continue using self-declarations of citizenship 
for Medicaid eligibility.1  At that time, OIG agreed to conduct an 
inspection on the extent to which States allow self-declaration. 
Subsequently, CMS withdrew the proposed rule.  However, OIG 
completed the inspection because of its potential value in the 
administration of the program. 
In recent years, CMS has encouraged self-declaration in an effort to 
simplify and accelerate the Medicaid application process.2 While the 
policy to allow applicants to self-declare citizenship can result in rapid 
enrollment, it can also result in inaccurate eligibility determinations 
for applicants who provide false citizenship statements.  As such, 
there are inherent challenges in trying to provide Medicaid benefits 
expeditiously while still ensuring the accuracy of eligibility 
determinations.  In a 2001 pamphlet, CMS provided information on 
how to maintain program integrity while attempting to simplify the 
1 Centers for Medicare & Medicaid Services, Medicaid Program: Self-Declaration of 
Citizenship, CMS-2085-P, Sept. 12, 2002. 
2 Centers for Medicare & Medicaid Services, Continuing the Progress:  Enrolling and 
Retaining Low-Income Families and Children in Health Care Coverage, Pub. No. 11000, 
Aug. 2001. 
  OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  i  EEE XXX EEE CCC UUU TTT III VVV EEE     SSS UUU MMM MMM AAA RRR YYY
application process. These strategies include verifying the accuracy of 
citizenship statements against other nonapplicant sources, such as 
State vital statistics databases, and/or conducting posteligibility-
focused reviews.3 
For this inspection, we gathered information from State Medicaid 
directors and their staff responsible for quality control activities. 
Additionally, we surveyed State Temporary Assistance for Needy 
Families (TANF) directors, State foster care directors, and Social 
Security Administration (SSA) officials. 
FINDINGS 
Forty-seven States allow self-declaration of U.S. citizenship for 
Medicaid; nearly all of these require evidence if statements seem 
questionable. Pursuant to Federal policy, States may accept a 
signed declaration as proof of U.S. citizenship from applicants seeking 
Medicaid benefits. Currently, 40 Medicaid directors report that their 
State allows self-declaration of citizenship. An additional seven 
report that self-declaration is sometimes allowed. The four remaining 
directors report that self-declaration is not permitted in their State. 
These States are Montana, New Hampshire, New York, and Texas. 
Forty-four of the forty-seven States that allow or sometimes allow 
self-declaration have prudent person policies which require evidence 
of citizenship if statements seem questionable to eligibility staff. 
Thirty-two of these have written prudent person policies, and the 
remaining 12 have unwritten, informal policies requiring 
documentation for questionable statements. 
Twenty-seven States do not verify the accuracy of any U.S. 
citizenship statements as part of their posteligibility quality 
control activities. In fiscal year 2003, 27 of the 47 States that allow 
self-declaration did not conduct quality control activities that included 
verification of statements of U.S. citizenship. Of the 20 States that 
did review statements, 9 did so for a nonrepresentative sample of the 
entire Medicaid population. Consequently, some groups that could 
pose vulnerability to Medicaid integrity were not included in the 
review sample. 
3 Centers for Medicare & Medicaid Services, Continuing the Progress: Enrolling and 
Retaining Low-Income Families and Children in Health Care Coverage, Pub. No. 11000, 
Aug. 2001. 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  ii  EE XX EE CC UU TT II VV EE    SS UU MM MM AA RR YY
Some States use types of evidence that are not accepted by CMS 
or SSA to document citizenship for Medicaid. As reported earlier, 
seven States sometimes allow and four States do not allow Medicaid 
applicants to self-declare citizenship. Of these 11 States, 4 use types 
of evidence to document citizenship that are not accepted by CMS or 
SSA. Furthermore, 13 of the 20 States that report conducting quality 
control to verify statements of U.S. citizenship use types of evidence 
that are not accepted by CMS or SSA, such as school records, family 
Bibles, voter registration records, and marriage licenses. 
Medicaid-related programs are more likely to verify citizenship; 
their verifications may be a useful resource for Medicaid.  SSA 
states that all applicants must provide documentary evidence of U.S. 
citizenship in order to receive a Social Security number or qualify for 
Supplemental Security Income (SSI) benefits. Forty-two of fifty-one 
foster care directors report that staff document U.S. citizenship when 
determining eligibility for Title IV-E foster care maintenance 
payments. Twenty-seven of fifty-one TANF directors report 
documenting or sometimes documenting citizenship for purposes of 
eligibility. 
In the majority of instances, we found that these Medicaid-related 
programs draw on evidence accepted by CMS or SSA to document 
statements of U.S. citizenship. These citizenship verifications may be 
a useful resource for Medicaid. 
RECOMMENDATIONS 
We recognize that there are challenges in providing Medicaid benefits 
expeditiously while ensuring the accuracy of eligibility determinations. 
By their nature, self-declaration policies have inherent vulnerabilities 
in that they can allow applicants to provide false statements of 
citizenship. As such, it is vital to have protections in place to prevent 
such practices. 
Based on the descriptive information we collected from States, we 
conclude that existing safeguards at the point of entry into Medicaid 
and during posteligibility quality control could allow false statements of 
citizenship to go undetected. Below are three recommendations for 
improving safeguards: 
 	 CMS should strengthen posteligibility quality controls in States that 
allow self-declaration. 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  iii  E X E C U T I V E   S U M M A R Y  
 	 CMS should issue a complete list of evidence that States may 
reference when determining eligibility. 
 	 CMS should explore allowing State Medicaid staff to use citizenship 
verifications from other Medicaid-related programs as an additional 
resource. 
AGENCY COMMENTS 
CMS concurred with our recommendations.  The agency further 
commented that it has already taken steps to improve safeguards to 
prevent applicants from providing false statements of citizenship.  The 
full text of CMSs comments is included in Appendix D. 
We note several issues with CMSs current efforts.  Specifically, CMS 
explained that, pursuant to Federal regulations, States must verify 
statements of citizenship for sampled active cases as part of their 
posteligibility quality control procedures.  We reiterate that this 
regulation applies only to States that operate traditional quality control. 
States that operate under a pilot or a section 1115 waiver with a quality 
control component are not required to verify all elements of eligibility, 
including statements of citizenship, as part of their posteligibility case 
file review. 
CMS also commented that States choosing to accept self-declaration of 
citizenship need to have systems in place for some type of posteligiblity 
check to ensure that the self-declaration procedure is reliable.  CMS 
stated that it is taking steps to do this by requiring a review of the 
accuracy of eligibility determinations as part of the Payment Error Rate 
Measurement (PERM) project.  Currently, the Office of Management 
and Budget is working with CMS to define the scope of the PERM 
project.  As of June, no decision has been made regarding the inclusion 
of errors related to Medicaid eligibility determinations.  
  OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  iv    T A B L E   O F   C O N T E N T S  

EXECUTIVE SUMMARY ......................................... i 

INTRODUCTION ................................................ 1 

FINDINGS... .................................................... 9 

States allowing self-declaration of citizenship ..................  9 

Posteligibility quality control activities........................  11 

Forms of evidence used to document citizenship................  14 

Practices in Medicaid-related programs .......................  15 

RECOMMENDATIONS ......................................... 18 

APPENDIXES .................................................. 20 

A:	  Evidence Accepted to Document Statements of Citizenship .. 20 

B: 	Medicaid Eligibility Quality Controls in States Allowing 

  Self-Declaration.......................................... 22 

C:	  Related Program Policies on Self-Declaration............... 24 

D: 	Agency Comments ....................................... 26 

ACKNOWLEDGMENTS ......................................... 29 
   I N T R O D U C T I O N  

OBJECTIVES 
Our objectives were to determine the extent to which States allow 
self-declaration of U.S. citizenship for Medicaid and related programs 
and to identify potential vulnerabilities, if any, associated with 
quality control activities and evidence used to document citizenship.   
BACKGROUND 
Title XIX of the Social Security Act (the Act) establishes Medicaid as a 
jointly funded, Federal-State health insurance program.  To qualify 
for the full range of Medicaid benefits provided under a State plan, an 
applicant must be either a citizen or a national of the United States or 
a qualified alien.4  Since 1986, verification of U.S. citizenship for 
purposes of Medicaid eligibility has been governed by section 1137(d) 
of the Act, which requires a declaration in writing, under penalty of 
perjury . . . stating whether the individual is a citizen or national of 
the United States.5  Pursuant to the Act, the Centers for Medicare & 
Medicaid Services (CMS) allows, but does not require, States to accept 
self-declaration of citizenship without requiring submission of 
additional documentary evidence.  In September 2002, CMS planned 
to issue a final rule that would permit States to continue using self-
declarations of citizenship for Medicaid eligibility.6  At that time, OIG 
agreed to conduct an inspection on the extent to which States allow 
self-declaration.  Subsequently, CMS withdrew the proposed rule. 
However, OIG completed its inspection because of its potential value 
in the administration of the program. 
In recent years, CMS has encouraged self-declaration in an effort to 
simplify and accelerate the Medicaid application process.7 While the 
policy to allow applicants to self-declare citizenship can result in rapid 
4 The Personal Responsibility and Work Opportunity Reconciliation Act of 1996  
   (PL 104-193). 
5 Social Security Act  1137 (d)(1)(A). 
6 Centers for Medicare & Medicaid Services, Medicaid Program: Self-Declaration of 
Citizenship, CMS-2085-P, Sept. 12, 2002. 
7 Centers for Medicare & Medicaid Services, Continuing the Progress:  Enrolling and 
Retaining Low-Income Families and Children in Health Care Coverage, Pub. No. 11000, 
Aug. 2001. 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  1  I N T R O D U C T I O N  
enrollment, it can also result in inaccurate eligibility determinations 
for applicants who provide false citizenship statements.  As such, 
there are inherent challenges in trying to provide Medicaid benefits 
expeditiously while still ensuring the accuracy of eligibility 
determinations.  In a 2001 pamphlet, CMS provided information on 
how to maintain program integrity while attempting to simplify the 
application process. These strategies include verifying the accuracy of 
citizenship statements against other nonapplicant sources, such as 
State vital statistics databases, and/or conducting posteligibility-
focused reviews.8 
Personal Responsibility and Work Opportunity Reconciliation Act of 1996 
The Personal Responsibility and Work Opportunity Reconciliation Act 
of 1996 (PRWORA) restricts eligibility for means-tested, federally 
funded public benefit programs to U.S. citizens or qualified aliens. 
This same legislation directed the Attorney General to establish 
verification guidance and procedures that States must follow in 
verifying the citizenship or immigration status of individuals applying 
for federally funded public benefit programs.  The U.S. Department of 
Justice (DOJ) issued interim guidance in 1997 (62 FR 61344) and 
proposed regulations (63 FR 41662) in 1998.  Final rules have not yet 
been issued. 
The proposed DOJ regulations would require that both citizens and 
qualified aliens who are applying for Medicaid provide documentary 
evidence to verify their status.  However, the proposed regulations 
would permit Federal benefit-granting agencies to establish 
alternative procedures for verifying citizenship. The agencies would 
be required (1) to publish regulations that provide for fair and 
nondiscriminatory procedures for verifying the citizenship of 
applicants for the benefit in question and (2) to obtain approval from 
the Attorney General for the alternative procedures. 
CMS set forth its policy concerning self-declaration in a letter dated 
September 10, 1998, to State Medicaid directors.  The letter explained 
that States may accept self-declaration of citizenship without 
8 Centers for Medicare & Medicaid Services, Continuing the Progress:  Enrolling and 
Retaining Low-Income Families and Children in Health Care Coverage, Pub. No. 11000, 
Aug. 2001. 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  2  II NN TT RR OO DD UU CC TT II OO NN
requiring submission of additional documentary evidence. On 
January 11, 2001, CMS published final regulations (42 CFR 
457.320(c)) that permit States to accept self-declaration of citizenship 
for applicants applying for coverage under the State Childrens 
Health Insurance Program, a State-run insurance program intended 
to provide health care coverage to certain low-income families.9 
Evidence of Citizenship 
The Department of Homeland Security (DHS), Bureau of Citizenship 
and Immigration Services is responsible for determining U.S. 
citizenship for persons in the United States.10 Currently, DHS does 
not have a comprehensive list of acceptable evidence that may be used 
to document citizenship. 
The CMS State Medicaid Manual contains two lists of evidence that 
may be accepted as proof of citizenship. These lists differ somewhat 
and neither is comprehensive. Examples of acceptable evidence listed 
in the manual include: 
  Birth certificate, 
  U.S. passport, 
  Report of Birth Abroad of a Citizen of the United States, and 
  Naturalization Certificate (INS Forms N-550 or N-570).11 
In its operations manual, the Social Security Administration (SSA) 
provides additional sources of evidence that may be used to document 
U.S. citizenship for purposes of establishing eligibility for SSA-
sponsored benefits. 
See Appendix A for a listing of the evidence accepted by CMS or SSA 
to document U.S. citizenship. 
Medicaid Eligibility Quality Control 
Federal regulations require State Medicaid agencies to conduct 
posteligibility quality control activities to eliminate or substantially 
reduce dollar losses resulting from eligibility errors.12 From 1978 to 
9 66 FR 2490. 

10 Homeland Security Act of 2002  402(3). 

11 State Medicaid Manual,  3212.3, Methods of Documenting United States Citizenship. 

12 42 CFR  431.800. 

OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  3  I N T R O D U C T I O N  
1993, States were required to conduct traditional eligibility case 
reviews of the Medicaid-eligible population.  As part of these 
traditional reviews, all States were required to review and verify 
elements such as citizenship and alienage, wage information, age, and 
residency. To verify information on citizenship, quality control staff 
were required to obtain documentation supporting the content of the 
declaration of citizenship.13 
In 1994, CMS offered States three options for conducting Medicaid 
Eligibility Quality Control (MEQC).  States could continue using 
traditional quality control, participate in a demonstration pilot 
program, or conduct quality control as part of a section 1115 waiver.14 
In fiscal year 2003, 39 States operated under a section 1115 waiver or 
an MEQC pilot.15 
MEQC pilots.  MEQC pilots allow States to develop innovative and 
targeted approaches for conducting quality control.  Under pilots, 
States may tailor their programs to look at error-prone areas, high- 
dollar areas, or special populations.  While operating under pilots, 
States are not required to conduct reviews of self-declaration of 
citizenship statements. 
Section 1115 waivers. Under section 1115 waivers, States may allow 
certain kinds of deviations from their State Medicaid plans, including 
the expansion of eligibility for those who would otherwise not be 
eligible for the Medicaid program.  Unless outlined in their contract 
with CMS, States operating under section 1115 waivers with quality 
control components are not required to conduct reviews of citizenship 
statements. 
Related Benefit Programs 
Other programs in which Medicaid recipients could potentially 
participate include Supplemental Security Income (SSI), Title IV-E 
foster care, and Temporary Assistance for Needy Families (TANF).  
We examined eligibility requirements and State policies and practices 
13 State Medicaid Manual, Chapter III, 7269.130. 
14 CMS Medicaid Quality Control Program, http://www.cms.hhs.gov/medicaid /meqc/mqcguid.asp, 
accessed Jan. 22, 2004. 
15 Centers for Medicare & Medicaid Services, National Overview of Medicaid Eligibility 
Quality Control for 2003, May 9, 2003. 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  4  II NN TT RR OO DD UU CC TT II OO NN
regarding self-declaration of U.S. citizenship for these related 
programs in an effort to identify a potential resource for Medicaid 
staff. Throughout this report, we refer to the SSI, foster care, and 
TANF programs as Medicaid-related programs. 
SSI. In general, States are required to provide Medicaid coverage to 
recipients of SSI. SSA requires that 
all Supplemental Security Income (SSI) applicants alleging U.S. 
citizenship must submit evidence. However, if an individual 
actually provided proof of his/her citizenship status in a prior 
claim for benefits from SSA, he/she will not have to resubmit that 
evidence.16 
Title IV-E foster care.  Section 471(21) of the Act requires States to 
provide Medicaid or equivalent health insurance coverage to children 
eligible to receive Title IV-E foster care program maintenance funds. 
For all children receiving Federal foster care maintenance payments, 
States are required to verify citizenship or immigration status.17 
TANF. Similar to Federal requirements related to documenting U.S. 
citizenship for Medicaid, current Federal law does not impose any 
specific documentation requirements, other than a signed declaration 
of U.S. citizenship, for TANF applicants claiming to be U.S. citizens.18 
SCOPE 
This inspection describes State practices to determine and document 
U.S. citizenship for Medicaid and related program eligibility, as well 
as State quality control activities. It does not identify the extent to 
which current Medicaid beneficiaries are ineligible on the basis of 
their citizenship. In addition, this inspection does not examine the 
extent to which eligible individuals fail to apply for Medicaid in States 
that require proof of U.S. citizenship as a condition of eligibility. 
16 The SSA Program Operations Manual System, Special Procedure for Establishing U.S. 
Citizenship for SSI Benefits, GN 00303.350, May 1995. 
17 ACF Child Welfare Policy Manual  WC Policy Database  Policy Questions & 
Answers, Question 9, June 4, 2003. 
18 Social Security Act  1137 (d)(1)(A). 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  5  I N T R O D U C T I O N

METHODOLOGY 
To identify States that allow self-declaration of U.S. citizenship for 
Medicaid and related programs, we gathered information from State 
Medicaid Directors and their staff responsible for quality control, as 
well as SSA officials, State foster care directors, and State TANF 
directors. 
The data presented in this report were collected from State 
representatives in the 50 States and the District of Columbia.  For 
reporting purposes, we refer to the District of Columbia as a State 
throughout our analysis. 
State Medicaid Directors 
To obtain descriptive information on all States practices with regard 
to self-declaration of U.S. citizenship, we administered telephone 
surveys to all 51 State Medicaid directors and their staff.  We asked 
directors about their States self-declaration practices and whether 
their State has a policy instructing eligibility staff to obtain additional 
verification when applicants statements appear incomplete, unclear, 
or inconsistent, which some States refer to as a prudent person 
policy.  We also asked directors to submit any evaluations or audits 
that were conducted within the last 5 years that looked at self-
declaration of U.S. citizenship for Medicaid.  We were able to speak 
with all directors during June and July 2003, giving us an overall 
response rate of 100 percent. 
MEQC Supervisors/ Medicaid Directors   
We administered another telephone survey to the 47 MEQC 
supervisors and/or Medicaid directors in States that permit self-
declaration of U.S. citizenship during December 2003.  We spoke with 
all 47 directors and/or supervisors in these States.  Survey questions 
for the 47 Medicaid directors and/or supervisors focused on: 
 	 Whether MEQC was conducted in a traditional format, under 
a section 1115 waiver, or under an MEQC pilot format during 
fiscal year 2003; 
 	 The extent to which citizenship statements were checked 
during quality control activities; 
 	 The types of documentation used to prove statements of U.S. 
citizenship; and 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  6   I N R O D U C T I O N  
 	 Whether, as part of the States quality control practices, self-
declaration of U.S. citizenship was included for review. 
For States operating a traditional MEQC program, we asked if staff 
conducted the required activities, as outlined in the CMS State 
Medicaid Manual.   
CMS Representatives  
We conducted interviews with representatives from the Medicaid 
State Operations group at CMS.  These interviews focused on how 
States are permitted to conduct MEQC activities.   
Social Security Administration Management Staff  
In January 2004, we conducted a telephone interview with 
management staff at SSA to determine if statements of U.S. 
citizenship are documented during and throughout the Social Security 
enumeration process and for SSI benefits.  We also asked questions on 
the extent to which citizenship data collected for SSA program 
eligibility are shared with State Medicaid agencies. 
Foster Care Directors 
We conducted a Web-based, self-administered survey of State foster 
care directors.  All 51 directors responded to our survey during 
October 2003. The survey requested information on whether foster 
care staff document a childs U.S. citizenship when determining 
eligibility for federally funded foster care maintenance payments. 
TANF Directors 
We conducted a self-administered, Web-based survey of State TANF 
directors.  All 51 directors responded to our survey during September 
2003. The survey requested States policies on self-declaration of U.S. 
citizenship to qualify for TANF benefits.   
Citizenship Evidence Accepted by CMS or SSA  
As mentioned earlier, DHS, the agency responsible for determining 
citizenship for a person in the United States, does not currently have a 
comprehensive reference list of acceptable evidence.  In the absence of 
an official document from DHS, we developed a comprehensive list of 
accepted evidence by combining the evidence accepted by CMS19 or 
19 State Medicaid Manual,  3212.3 and 7269.130. 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  7 I N T R O D U C T I O N  
SSA20 for purposes of documenting citizenship for program eligibility.  
We then compared the forms of evidence States report using to 
document U.S. citizenship for Medicaid and related programs with this 
comprehensive list.  See Appendix A for a complete listing of accepted 
evidence used during our analysis.   
We conducted this inspection in accordance with the Quality 
Standards for Inspections issued by the Presidents Council on 
Integrity and Efficiency. 
20 The SSA Program Operations Manual System, Establishing U.S. Citizenship for all SSA 
Programs, GN 00303.300, July 12, 2002. 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  8  FF II NN DD II NN GG SS   
  F I N D I N G S  
Forty-seven States allow self-declaration of U.S.  Pursuant to the Act, States may 
citizenship for Medicaid; nearly all of these require  accept a signed declaration as 
proof of U.S. citizenship from 
evidence if statements seem questionable 
applicants seeking Medicaid 
benefits.21  Forty-seven of fifty-one Medicaid directors report that 
their State allows or sometimes allows self-declaration of U.S. 
citizenship.  For the four remaining States (Montana, New 
Hampshire, New York, and Texas) directors report that applicants 
must submit documentary evidence to verify U.S. citizenship 
statements. Table 1 displays each States policy on self-declaration of 
U.S. citizenship for Medicaid. 
Seven directors report that although their State sometimes allows 
applicants to self-declare U.S. citizenship, documentation is required 
under some circumstances.  Four of these directors indicate that 
documentation is required for the aged, blind, and disabled 
populations. Other circumstances in which States sometimes ask for 
documentation include when the applicant was born outside of the 
United States or if information related to the applicants place of birth 
does not exist in the States vital statistics database.   
With the exception of one State that verifies self-declaration 
statements through its vital statistics database, no other States 
volunteer that they obtain verification of citizenship statements from 
other nonapplicant sources.   Further, none of the directors volunteer 
that eligibility staff currently utilize citizenship verification 
information from related programs such as TANF or foster care. 
Nearly all States that allow self-declaration require evidence of U.S. 
citizenship if statements seem questionable during the eligibility process 
Forty-four of the forty-seven States that permit or sometimes permit 
self-declaration report that they have a written or informal prudent 
person policy requiring documentation if the statements of the 
applicant seem questionable.  Of these, 32 States have a written 
policy to guide staff in these situations.  An example of a written 
policy instructs Medicaid eligibility staff that 
21 CMS letter to State Medicaid directors, September 10, 1998. 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  9  F I N D I N G S  
Table 1:  State Policies on Self-Declaration of Citizenship for Medicaid 
State  Allowed  Sometimes  Not  Prudent  State  Allowed Sometimes  Not  Prudent 
Allowed  Allowed  Person  Allowed  Allowed  Person 
Policy  Policy 
AL  (cid:57)  Written  NV  (cid:57)  Written 
AK  (cid:57)  Written  NH  (cid:57)  NA 
AZ  (cid:57)  Written  NJ  (cid:57)  Written 
AR  (cid:57)  Informal  NM  (cid:57)  Written 
CA  (cid:57)  Written  NY  (cid:57)  NA 
CO  (cid:57)  None  NC  (cid:57)  Written 
CT  (cid:57)  Written  ND  (cid:57)  Written 
DE  (cid:57)  Informal  OH  (cid:57)  Written 
DC  (cid:57)  None  OK  (cid:57)  Written 
FL  (cid:57)  Written  OR  (cid:57)  Written 
GA  (cid:57)  Written  PA  (cid:57)  Written 
HI  (cid:57)  Informal  RI  (cid:57)  Informal 
ID  (cid:57)  Informal  SC  (cid:57)  Written 
IL  (cid:57)  Informal  SD  (cid:57)  Informal 
IN  (cid:57)  Informal  TN  (cid:57)  Informal 
IA  (cid:57)  Written  TX  (cid:57)  NA 
KS  (cid:57)  Written  UT  (cid:57)  Written 
KY  (cid:57)  Written  VT  (cid:57)  Written 
LA  (cid:57)  Written  VA  (cid:57)  Informal 
ME  (cid:57)  Informal  WA  (cid:57)  Written 
MD  (cid:57)  Written  WV  (cid:57)  Written 
MA  (cid:57)  None  WI  (cid:57)  Written 
MI  (cid:57)  Written  WY  (cid:57)  Written
MN  (cid:57)  Written    Totals  40  7  4  -
MS  (cid:57)  Written 
Written  - - - 32
MO  (cid:57)  Informal 
MT  (cid:57)  NA    Informal  - - - 12
NE  (cid:57)  Written   None  - - - 3 
Source:  OIG analysis of State policies on self-declaration of U.S. citizenship, 2004 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  10  F I N D I N G S  
when statements of client are incomplete, unclear, or 
inconsistent, or when other circumstances in the particular case 
indicate to a prudent person that further inquiry must be made, 
the worker shall obtain additional verification before eligibility 
is determined. 
The remaining 12 States have unwritten, informal prudent person 
policies requiring additional verification when eligibility staff deem 
statements questionable. 
Medicaid directors report they allow self-declaration to increase access and 
express concern about increased costs if the policy is prohibited 
We asked the 47 State Medicaid directors in States allowing self-
declaration their reasons for not requiring evidence of U.S. 
citizenship.  Twenty-five respondents say that they have been 
encouraged by CMS to simplify their application processes in order to 
reduce barriers to health care access.  In addition, 17 respondents 
report that through their posteligibility quality control activities, they 
have not seen a problem with self-declaration of citizenship. 
We asked what costs, if any, Medicaid applicants would incur if all 
were required to provide documentary evidence of U.S. citizenship. 
Twenty-eight of forty-seven directors report that it would delay 
eligibility determination. In addition, 25 directors comment that it 
would result in increased eligibility personnel costs.  Twenty-one 
directors also report that it would be burdensome and/or expensive for 
applicants to obtain copies of birth certificates or other 
documentation.  
Federal regulations require 
Twenty-seven States do not verify the accuracy of U.S. 
State Medicaid agencies to 
citizenship claims as part of their posteligibility quality 
conduct posteligibility quality 
control activities 
control activities to eliminate 
or substantially reduce dollar losses resulting from eligibility 
errors.22  States may conduct MEQC activities in a traditional 
format, under an MEQC pilot format, or as part of a section 1115 
waiver. In fiscal year 2003, 27 of the 47 States that allow self-
declaration did not conduct quality control activities that included 
verification of statements of U.S. citizenship. 
22 42 CFR  431.800. 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  11  FF II NN DD II NN GG SS  
Of the 20 States that did review statements of U.S. citizenship, 9 did 
so for a nonrepresentative sample of the entire Medicaid population. 
Consequently, some groups that may pose vulnerability to Medicaid 
integrity were not included in the sample of applications that were 
reviewed. See Appendix B for a list of States quality control 
activities. 
Three States operating traditional MEQC programs do not conduct required 
quality control activities 
Under traditional MEQC, States are required to verify that sampled 
applicants are U.S. citizens. Three of the eleven States that operated 
a traditional MEQC program and allowed self-declaration in fiscal 
year 2003 did not conduct required eligibility quality control for U.S. 
citizenship. These States report that they did not collect documentary 
evidence to support statements of U.S. citizenship for sampled 
applicants. (See Table 2.) 
Table 2:  Medicaid Quality Control on Self-Declaration of U.S. Citizenship
by Type of MEQC Program 
Total 
Does Not Conduct  Conducts  Number of States 
Type of MEQC  MEQC for Self- MEQC for  That Allow Self-
F I N D I N G S  
Program  Declaration  Self-Declaration  Declaration 
Traditional  3  8  11 
Pilot*  20  8  28 
Waiver  4  4  8 
Overall total 
27  20  47 
States 
*In fiscal year 2003, Tennessee operated under both an MEQC pilot and an 1115 waiver. We considered Tennessee 
a pilot program because it conducted MEQC activities under its pilot, which included the entire Medicaid population. 
Source: OIG analysis of State MEQC practices, 2004 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  12  FF II NN DD II NN GG
 SS  
Twenty MEQC pilot States do not monitor self-declaration of U.S. citizenship 
While operating under an MEQC pilot, States may, but are not 
required to, conduct posteligibility reviews of self-declaration of 
citizenship statements. Twenty of the twenty-eight States that 
permit self-declaration of U.S. citizenship and operated under a pilot 
program in fiscal year 2003 did not obtain documentary evidence to 
support beneficiaries statements of U.S. citizenship for any portion of 
their Medicaid population. Eight States conducted quality control on 
self-declarations of citizenship, but seven did so for a 
nonrepresentative sample which accounted for less than 8 percent of 
the Medicaid population. These samples did not include certain 
populations that may pose vulnerability to Medicaid integrity. 
Four section 1115 waiver States do not address self-declaration of U.S. 
citizenship 
While operating under a section 1115 waiver with a quality control 
component, a State may, but is not required to, conduct reviews of 
self-declaration of citizenship statements. Four of the eight States 
that allow Medicaid applicants to self-declare U.S. citizenship and 
operated under section 1115 waivers in fiscal year 2003 did not obtain 
and verify documentary evidence to support statements of U.S. 
citizenship. Of the four section 1115 waiver States that verify 
statements of U.S. citizenship for quality control purposes, two 
conducted MEQC for only a subset of the entire Medicaid population. 
Only one State reports conducting an audit looking at self-declaration of 
U.S. citizenship, and it found vulnerabilities 
We asked States for any quality control audits or evaluations that 
looked at self-declaration of citizenship. Only one State director 
provided an audit on this topic. This audit report found 
vulnerabilities related to the process of self-declaration of U.S. 
citizenship. 
Specifically, the audit, conducted in January 2002 by the Secretary of 
the State of Oregon, found that the State provided full Medicaid 
benefits to 25 beneficiaries (of the sample of 812) who were 
noneligible noncitizens. The audit report concludes that there are 
potential risks involved in allowing applicants to self-declare their 
U.S. citizenship on mail-in applications, which do not allow workers to 
verify the accuracy of statements of U.S. citizenship. They estimate 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  13  F I N D I N G S  
that the risk could result in an annual cost of about $2 million, based 
on a 1 percent estimate of noneligible noncitizens receiving Medicaid 
benefits.23 
Some States use types of evidence that are 
not accepted by CMS or SSA to document 
citizenship for Medicaid 
Four States use forms of evidence that are not accepted by CMS or SSA to 
document citizenship for initial Medicaid eligibility 
As reported earlier, seven States sometimes allow and four States do 
not allow Medicaid applicants to self-declare citizenship.  Of these 11 
States, 4 use types of evidence to document citizenship that are not 
accepted by CMS or SSA.  Specifically, two States allow the use of a 
school record to document citizenship and two allow use of a family 
Bible as documentation.24 
Seven of eleven States that sometimes allow or do not allow self-
declaration report accepting documentation that is accepted by CMS 
or SSA.  These include public birth records, U.S. passports, and 
naturalization certificates.  
Thirteen States use types of evidence that are not accepted by CMS or SSA 
to verify statements of U.S. citizenship for posteligibility quality control 
purposes 
Thirteen of the twenty States that report conducting quality control to 
verify statements of U.S. citizenship use forms of documentation that 
are not accepted by CMS or SSA.  For example, 11 of these 13 States 
report using records of receipt of SSI to verify citizenship.  While one 
of the primary sources included in the CMS State Medicaid Manual to 
verify citizenship and alienage declarations is Record of receipt of 
23 Audit Report:  Department of Human Services Oregon Health Plan Eligibility Review, 
Report No. 2002-03, January 3, 2002, p. 1. 
24 According to section 7269.1 of the State Medicaid Manual, States may accept evidence of 
continuous residence in the United States prior to June 30, 1948.  Among the records 
accepted to prove continuous residence are school records, a marriage license, a voter 
registration card, an insurance policy, military service records, and a Social Security 
number.  The directors identified here did not report accepting documentation that was 
dated prior to June 30, 1948.    
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  14  FFF III NNN DDD III NNN GGG SSS  
SSI,25 in discussions with SSA, we found that verification of receipt 
of SSI does not guarantee that the Medicaid applicant or beneficiary 
is a U.S. citizen. Medicaid agencies must take the additional step of 
verifying the Alien/Refugee code in the State Data Exchange report 
files, which provide States with eligibility, payment, and demographic 
data relating to SSI recipients, to substantiate that evidence of U.S. 
citizenship was submitted for SSI eligibility purposes. 
Other examples of documentation that is not accepted by CMS or SSA 
but which State Medicaid directors report using for quality control 
purposes are voter registrations, proof of Medicare Part A, school 
records, childrens birth certificates to prove a parents citizenship 
status, marriage licenses, and even other self-declaration statements. 
Medicaid applicants may potentially 
Medicaid-related programs are more 
participate in related programs such as 
likely to document citizenship; their 
SSI, foster care, and TANF. We found 
verifications may be a useful resource for 
that these related programs are more 
Medicaid 
likely than Medicaid to document 
citizenship and most often use evidence that is accepted by CMS or 
SSA to verify this status. These verifications may be a useful 
resource for Medicaid staff. Appendix C provides information on 
related programs policies and use of documentation on a State-by-
State basis. 
United States citizenship is always documented for enumeration and SSI 
The SSA officials report that all applicants must provide documentary 
evidence of U.S. citizenship or legal status in order to receive a Social 
Security number (enumeration) or to qualify for SSI benefits. In some 
cases, SSAs prior determination of citizenship is accepted as a means 
for documenting U.S. citizenship. However, SSA is currently 
reviewing this policy to ensure that it does not rely on inadequate 
documentation that was submitted for purposes of enumeration and 
SSI in prior years. 
As indicated earlier, in discussions with SSA officials, we found that 
verification of receipt of SSI does not prove U.S. citizenship. 
25 It is important to note that this list does not distinguish between appropriate sources to 
verify U.S. citizenship versus appropriate sources to verify alienage. 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  15  FF II NN DD II NN GG SS  
Eligibility staff must take the additional step of verifying the 
Alien/Refugee code in the State Data Exchange report files. 
Forty-two States document the citizenship status of children receiving Title 
IV-E foster care benefits, as required by the Administration for Children and 
Families 
The Administration for Children and Families requires that foster 
care eligibility staff document U.S. citizenship status for purposes of 
federally funded Title IV-E foster care maintenance payment 
eligibility.26  Forty-two of fifty-one foster care directors report that 
staff document U.S. citizenship when determining eligibility for 
federally funded foster care maintenance. Seven directors report that 
staff sometimes document U.S. citizenship, and two say citizenship is 
never documented. 
Among the seven foster care directors who indicate that U.S. 
citizenship is sometimes not documented, circumstances under which 
no documentation occurs vary significantly. Examples include the 
rare occurrence when a child falls under category 85, undocumented 
alien emergency situation coverage and when a parent or other 
reliable source reports a child is a citizen. 
Fifteen States document citizenship to determine TANF eligibility 
Similar to requirements for Medicaid, States may permit TANF 
applicants to self-declare U.S. citizenship status as a condition of 
eligibility. Fifteen of fifty-one directors report verifying citizenship for 
TANF eligibility. Twelve directors report that it is their States policy 
to sometimes verify applicants statements of U.S. citizenship. 
Twenty-four TANF directors report that their State allows self-
declaration for eligibility purposes. 
Related programs commonly use types of evidence that are accepted by 
CMS or SSA to verify citizenship 
Thirty-five of the forty-nine foster care directors that verify or 
sometimes verify U.S. citizenship for children entering their States 
foster care program use types of evidence that are accepted by CMS or 
SSA. The remaining 14 include forms of documentation that are not 
accepted. Examples of these include green cards, Social Security 
26 ACF Child Welfare Policy Manual  WC Policy Database  Policy Questions & 
Answers, Question 9, June 4, 2003. 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  16  FF II NN DD II NN GG SS  
numbers, citizenship declarations by parents/caregivers, military 
service records, and family Bibles. 
Twenty of the twenty-seven States that verify or sometimes verify 
U.S. citizenship for TANF eligibility purposes use evidence accepted 
by CMS or SSA. The remaining States report using evidence that is 
not accepted, such as voter registration cards, school records, and/or 
family Bibles. 
In the majority of instances, we found that related programs draw on 
evidence that is accepted by CMS or SSA to verify statements of 
citizenship. In States where related programs both verify statements 
of citizenship and use generally accepted documentation to do so, 
these verifications may be a useful resource for Medicaid. 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  17    RR EE CC OO MM MM EE NN DD AA TT II OO NN SS   

We recognize that there are challenges in providing Medicaid benefits 
expeditiously while ensuring the accuracy of eligibility determinations. 
By their nature, self-declaration policies have inherent vulnerabilities 
in that they can allow applicants to provide false statements of 
citizenship. As such, it is vital to have protections in place to prevent 
such practices. 
Based on the descriptive information we collected from States, we 
conclude that existing safeguards at the point of entry into Medicaid 
and during posteligibility quality control could allow false statements of 
citizenship to go undetected. Below are three recommendations for 
improving safeguards: 
CMS should strengthen posteligibility quality controls in States that allow 
self-declaration 
Currently, 47 States allow self-declaration of citizenship for Medicaid.  
Over half of these never verify citizenship statements as part of their 
posteligibility quality control procedures.  In States that do check 
statements, most do so for a subset of the entire Medicaid population.  
More examinations are needed to determine if there are problems 
resulting from this policy.  Therefore, CMS should encourage States 
that allow self-declaration of citizenship to conduct reviews on the 
accuracy of these statements.   Findings from these reviews could then 
be used to determine the extent to which this policy results in 
inaccurate eligibility determinations.  
CMS should issue a complete list of evidence that States may reference 
when determining eligibility 
Four of the eleven States that require or sometimes require evidence of 
citizenship for initial Medicaid eligibility use types of evidence that are 
not accepted by CMS or SSA.  Further, 13 of the 20 States that report 
conducting quality control to verify statements of citizenship use types 
of evidence that are not accepted by CMS or SSA.  In its State Medicaid 
Manual, CMS has two lists of evidence that are slightly different, and 
neither is comprehensive.  To better ensure that States collect evidence 
that is consistent with CMS standards, CMS should issue a complete 
list of evidence that States may reference when determining eligibility.  
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  18  RR EE CC OO MM MM EE NN DD AA TT II OO NN SS  
CMS should explore allowing State Medicaid staff to use citizenship 
verifications from other Medicaid-related programs as an additional 
resource 
When looking at related programs including SSI, Title IV-E, and TANF, 
we found that these programs are more likely to verify citizenship as a 
condition of eligibility and, in most cases, use types of evidence that are 
accepted by CMS or SSA. If CMS determines it appropriate, States that 
allow applicants to self-declare citizenship could perform checks on the 
accuracy of these statements using related programs verification 
information. This step would not add a burden to applicants and would 
not require the collection of additional documentation. In Appendix C, 
we identify which States and programs verify statements of citizenship 
and use evidence accepted by CMS or SSA. 
AGENCY COMMENTS 
CMS concurred with our recommendations. The agency further 
commented that it has already taken steps to improve safeguards to 
prevent applicants from providing false statements of citizenship. The 
full text of CMSs comments is included in Appendix D. 
We note several issues with CMSs current efforts. Specifically, CMS 
explained that, pursuant to Federal regulations, States must verify 
statements of citizenship for sampled active cases as part of their 
posteligibility quality control procedures. We reiterate that this 
regulation applies only to States that operate traditional quality control. 
States that operate under a pilot or a section 1115 waiver with a quality 
control component are not required to verify all elements of eligibility, 
including statements of citizenship as part of their posteligibility case 
file review. 
CMS also commented that States choosing to accept self-declaration of 
citizenship need to have systems in place for some type of posteligiblity 
check to ensure that the self-declaration procedure is reliable. CMS 
stated that it is taking steps to do this by requiring a review of the 
accuracy of eligibility determinations as part of the Payment Error Rate 
Measurement (PERM) project. Currently, the Office of Management 
and Budget is working with CMS to define the scope of the PERM 
project. As of June, no decision has been made regarding the inclusion 
of errors related to Medicaid eligibility determinations. 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  19    A P P E N D I X   ~   A

Types of Evidence Accepted by CMS or SSA to Document U.S. 
Citizenship 
Documentation Type  CMS  SSA 
A birth certificate showing birth in 
(cid:57)  (cid:57) 
the United States 
Religious record of birth recorded 
in the United States or its  (cid:57)  (cid:57) 
territories within 3 months of 
birth, which indicates a U.S. 
place of birth 
(cid:57)  (cid:57)
United States passport 
Form FS-240 (Report of Birth 
Abroad of a Citizen of the United  (cid:57)  (cid:57) 
States) 
(cid:57)  (cid:57)
Form FS-545 (Certification of 
Birth) 
U.S. Citizen I.D. Card Form I-97 
(United States Citizen  (cid:57)  (cid:57) 
Identification Card) 
Form N-550 and N-570 
(cid:57)  (cid:57) 
(Certificate of Naturalization) 
(cid:57)  (cid:57)
Forms N-560 and N-561 
Evidence of continuous 
residence in the United States 
prior to June 30, 1948 (including 
school records; marriage license; 
(cid:57)
voter registration card; insurance 
policy; military service records; 
Social Security number issued 
prior to June 30, 1948, etc.) 
(cid:57)  (cid:57)
Record receipt of SSI* 
Bureau of Vital Statistics, local 
government, hospital, or clinic  (cid:57) 
records of birth and parentage 
Court records of parentage,  (cid:57) 
juvenile proceedings, or child 
support 
  Sources:  CMS State Medicaid Manual  3212 and 7269 and the SSA Program Operations Manual System:  GN 00303.300 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  20  A P P E N D I X ~ A  

Documentation Type 
CMS  SSA 
American Indian Card (first 
(cid:57)  (cid:57) 
issued by INS in 1983) 
Form DS-1350 (Certification of 
Report of Birth) issued by the 
State Department  (cid:57) 
Northern Mariana Identification 
(NMI) Card, first issued by INS in 
1987, to identify naturalized 
citizens born in the NMI before 
November 3, 1986  (cid:57)  (cid:57) 
Evidence of civil service 
employment by the U.S. 
(cid:57) 
Government before June 1, 1976 
  Sources:  CMS State Medicaid Manual  3212 and 7269 and the SSA Program Operations Manual System:  GN 00303.300 
*Note: In discussions with SSA, we found that verification of receipt of SSI alone does not guarantee 
that the Medicaid applicant or beneficiary is a U.S. citizen.  Medicaid agencies must take the 
additional step of verifying the Alien/Refugee code in the State Data Exchange report files.  
Therefore, while CMS does accept this form of documentation, we determined that this might not 
prove U.S. citizenship.
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  21    A P P E N D I X   ~   B  

Fiscal Year 2003 MEQC in the 47 States Allowing Self-Declaration of 
U.S. Citizenship 
Conducts Some MEQC 
CMS MEQC 
State  On Self-Declaration Of U.S. 
Categorization 
Citizenship 
Alabama  Traditional  Yes 
Alaska  Pilot  No 
Arizona  Waiver  Yes 
Arkansas  Waiver  Yes 
California  Pilot  Yes 
Colorado  Pilot  No 
Connecticut Traditional  Yes 
Delaware  Pilot  No 
District of Columbia  Pilot  No 
Florida  Traditional  Yes 
Georgia  Traditional  No 
Hawaii  Waiver  Yes 
Idaho  Pilot  No 
Illinois  Pilot  Yes 
Indiana  Pilot  Yes 
Iowa  Pilot  No 
Kansas  Pilot  No 
Kentucky  Pilot  No 
Louisiana  Pilot  No 
Maine  Traditional  No 
Maryland  Waiver  Yes 
Massachusetts  Waiver  No 
Michigan  Traditional  Yes 
Minnesota  Waiver  No 
Mississippi  Traditional  Yes 
Missouri  Waiver  No 
Nebraska  Pilot  No 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  22  A P P E N D I X ~ B  

Conducts Some MEQC 
CMS MEQC 
State  On Self-Declaration Of U.S. 
Categorization 
Citizenship 
Nevada  Pilot  No 
New Jersey  Pilot  No 
New Mexico  Pilot  No 
North Carolina  Pilot  No 
North Dakota  Traditional  Yes 
Ohio  Pilot  No 
Oklahoma  Traditional  No 
Oregon  Waiver  No 
Pennsylvania  Pilot  Yes 
Rhode Island  Traditional  Yes 
South Carolina  Pilot  Yes 
South Dakota  Pilot  No 
Tennessee  Pilot*  Yes 
Utah  Pilot  Yes 
Vermont  Traditional  Yes 
Virginia  Pilot  No 
Washington  Pilot  No 
West Virginia  Pilot  No 
Wisconsin  Pilot  Yes 
Wyoming  Pilot  No
    Total Traditional  11  -
Total Pilot  28  -
Total Waiver  8  -
Total Yes  - 20
Total No  - 27  
Source:  OIG analysis of State MEQC practices, 2004 
*In fiscal year 2003, Tennessee operated under both an MEQC pilot and an 1115 waiver.  We considered Tennessee a 
program because it conducted MEQC activities under its pilot, which included the entire Medicaid population. 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  23    A P P E N D I X   ~   C  

Related Programs Policies on Self-Declaration and Their Use of 
Documentation Accepted by CMS or SSA:  A Guide for Medicaid 
Eligibility Staff 
TANF Uses  Foster Care 
Foster 
Evidence  Uses Evidence 
State  Medicaid  TANF 
Care 
Accepted by CMS  Accepted by 
or SSA  CMS or SSA 
AL      Yes    No 
AK      Yes    Yes 
AZ      No    Yes 
AR      NA    Yes 
CA      Yes    Yes 
CO      NA    Yes 
CT      No    No 
DE      No    Yes 
DC      NA    Yes 
FL      NA    No 
GA      NA    No 
HI      Yes    No 
ID      NA    No 
IL      Yes    Yes 
IN      Yes    Yes 
IA      Yes    Yes 
KS      NA    Yes 
KY      NA    No 
LA      NA    Yes 
ME      NA    Yes 
MD      Yes    Yes 
MA      No    NA 
MI      Yes    Yes 
MN      NA    NA 
MS      NA    Yes 
MO      Yes    Yes 
MT      Yes    Yes 
NE      NA    No 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  24    A P P E N D I X   C  

TANF Uses  Foster Care 
Evidence  Foster  Uses Evidence 
State  Medicaid  TANF 
Accepted by  Care  Accepted by 
CMS or SSA  CMS or SSA 
NV      Yes    Yes 
NH      No    Yes 
NJ      No    Yes 
NM      NA    No 
NY      Yes    Yes 
NC      NA    No 
ND      Yes    No 
OH      Yes    Yes 
Ok      NA    Yes 
OR      NA    Yes 
PA      No    Yes 
RI      Yes    Yes 
SC      NA    Yes 
SD      NA    Yes 
TN      NA    Yes 
TX      Yes    No 
UT      NA    No 
VT      Yes    Yes 
VA      NA    Yes 
WA      NA    Yes 
WV      NA    Yes 
WI      Yes    Yes 
WY      Yes    No
 Total   40  24  - 2  -
Total   7  12  - 7  -
Total   4  15  - 42  -
Total Yes  - - 20  - 35
 Total No  - - 7  - 14
 Total NA  - - 24  - 2
 Source:  OIG analysis of related program policies on self-declaration of U.S. citizenship, 2004 
* Because SSA always verifies the citizenship status of applicants for a Social Security number or for  
SSI, a State-by-State description of this policy does not appear in this table. 
 Denotes a State that reports permitting self-declaration of U.S. citizenship or reports not requiring 
evidence of citizenship to qualify for federally funded benefits.  
 Denotes a State that reports sometimes permitting self-declaration of U.S. citizenship.  
 Denotes a State that reports never permitting self-declaration or requiring evidence of U.S.

citizenship to qualify for this federally funded benefit.

OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  25    A P P E N D I X   ~   D  

OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  26 
 A P P E N D I X ~ D  

OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  27 
 A P P E N D I X ~ D  

OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  28 
   EA NC DK  N NO OWTLEESD  G M E N T S  

This report was prepared under the direction of Jodi Nudelman, Acting 
Regional Inspector General for Evaluation and Inspections in the New 
York Regional Office.  Other principal Office of Evaluation and 
Inspections staff who contributed include: 
Ellen Vinkey, Team Leader 
Christi Macrina, Project Leader 
David Rudich, Program Analyst 
Linda Ragone, Deputy Regional Inspector General, Region III 
Tricia Davis, Director, Medicare and Medicaid Branch 
Elise Stein, Director, Public Health and Human Services 
Linda Hall, Program Specialist 
Barbara Tedesco, Mathematical Statistician 
OEI-02-03-00190  SELF-DECLARATION OF U.S. CITIZENSHIP FOR MEDICAID  29