DEPARTMENT OF HEALTH & HUMAN SERVICES 
Health Care Financing Administration  
 Center for Medicaid and State Operations 
7500 Security Boulevard 
Baltimore, MD 21244-1850 
May 2, 1997  
Dear State Medicaid Director  
NATURALIZATION PROCESS AND MEDICAID    
We are writing to provide you information about the impact of the INS naturalization regulations that will provide a 
method for certain disabled noncitizens, who may be at risk of losing their Medicaid eligibility, to become citizens.  
Most applicants for naturalization must pass examinations demonstrating proficiency in ordinary English and knowledge 
of U.S. history and government. However, in the past certain noncitizens with disabilities have had difficulty meeting 
these requirements of the naturalization process. To address this problem, Congress amended the Immigration and 
Nationality Act to permit INS to grant disabled individuals a waiver of the English language proficiency and knowledge 
of U.S. history and government examinations. Such individuals must still be able to assent to the oath of allegiance. On 
March 19, 1997, the Immigration and Naturalization Service published a final rule with request for comments to 
implement the waiver provisions.  
To obtain an exemption, the applicant for naturalization must request and file an application for a disability exemption 
(Form N-648), with their applications for naturalization (Form N-400), accompanied by the appropriate fees for both 
forms. The Form N-648, Medical Certification for Disability Exceptions, must be completed by a licensed physician or 
psychologist, as specified under the regulation, who has examined the applicant and determined that, based on the 
individual's medically determinable physical or mental impairment or combination of impairments, the applicant is 
incapable of meeting the English language and U.S. government and history requirements under the INA. States are 
permitted to pay for the costs associated with the physician's or psychologist's examination or completion by the provider 
of the waiver application form for a Medicaid beneficiary.  
We encourage you to assist Medicaid beneficiaries who may be eligible for this exemption by authorizing reimbursement 
under Medicaid to providers who perform the certification specified in 8 CFR part 312. We have attached a copy of the 
regulation, an INS Fact Sheet, and the required medical certification form for ease of reference.  
A copy of this letter is also being sent to the Mental Retardation and Developmental Disability Directors in your State.  
Thank you for you continued cooperation in the implementation of the many new immigrant-related changes in the 
Medicaid program.  
Sincerely,   
/s/   
Judith D. Moore   
Acting Director  Medicaid Bureau  
 
Attachments  
cc:  All Regional Administrators  
All Associate Regional Administrators  Division of Medicaid  
Eligibility TAG Members  
Jennifer Baxendall  National Governors Association  
Lee Partridge  American Public Welfare Association  
Joy Wilson  National Conference of State Legislators  
State Mental Retardation and Developmental Disability Directors  
Lloyd Bishop  Office of Legislative and Inter-Governmental Affairs, HCFA