DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop C2-21-15 
Baltimore, Maryland 21244-1850 
 
 
Center for Medicaid & State Operations  
 
February 22, 2007 
SMDL #07-002 
 
 
Dear State Medicaid Director: 
 
We are writing to inform you of recent legislative changes made to section 1903(x) of the Social 
Security Act (the Act), which establishes new requirements related to documentation of 
citizenship by Medicaid applicants or recipients who declare they are citizens or nationals of the 
United States.  Guidance on the implementation of section 1903(x) of the Act was provided 
through a State Medicaid Directors letter on June 9, 2006, and the publication of an Interim 
Final Rule with comment period on July 12, 2006.  Section 405(c)(1) of the Tax Relief and 
Health Care Act of 2006 (TRHCA), P.L. 109-432, which amends section 1903(x), was enacted 
on December 20, 2006.   
 
The TRHCA amends section 1903(x) by replacing the word alien in 1903(x)(2) with the 
phrase individual declaring to be a citizen or national of the United States.  This change 
corrects in statute the scriveners error as described in the Interim Final Rule with comment 
period.  This correction does not affect the policy as described in the Interim Final Rule. 
 
The TRHCA also amended section 1903(x)(2) to exempt two additional groups of individuals 
from the provisions requiring presentation of satisfactory documentary evidence of citizenship or 
nationality.  These groups are: 
 
  Individuals receiving disability insurance benefits under section 223 of the Act or 
monthly benefits under section 202 of the Act, based on such individuals disability (as 
defined in section 223(d) of the Act); and 
  Individuals with respect to whom child welfare services are made available under part B 
of title IV on the basis of being a child in foster care, or adoption or foster care assistance 
is made available under part E of title IV of the Act. 
 
It should be noted that policy outlined in this letter, as provided for by TRHCA, Division B, 
Section 405(c)(1)(A) supersedes the policy outlined in the Interim Final Rule published on 
July 12, 2006, regarding these groups. 
 
These amendments made to 1903(x) by TRHCA are effective as if included in section 6036 of 
the Deficit Reduction Act of 2005. 
 
In addition, important amendments were made to the title IV-E program, and the Childrens 
Bureau will be issuing guidance on those provisions.  Page 2  State Medicaid Director 
 
The Centers for Medicare & Medicaid Services contact for this new legislation is Jean Sheil, 
Director, Family and Childrens Health Program Group, who may be reached at 410-786-5647. 
 
            Sincerely, 
 
/s/ 
 
            Dennis G. Smith  
            Director 
 
cc:   
 
CMS Regional Administrators 
 
CMS Associate Regional Administrators, 
    Division of  Medicaid and Childrens Health 
 
Martha Roherty 
Director, Health Policy Unit 
American Public Human Services Administration 
 
Joy Wilson 
Director, Health Committee 
National Conference of State Legislatures 
 
Matt Salo 
Director of Health Legislation 
National Governors Association 
 
Jacalyn Bryan Garden 
Director of Policy and Programs 
Association of State and Territorial Health Officials 
 
Christie Raniszewski Herrara 
Director, Health and Human Services Task Force 
American Legislative Exchange Council 
 
Lynne Flynn 
Director for Health Policy 
Council of State Governments