DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland 21244-1850 
 
Centers for Medicaid and State Operations 
 
June 9, 2006                  SMD 06-012  
 
 
Dear State Medicaid Director: 
 
This is one of a series of letters that provides guidance on the implementation of the Deficit 
Reduction Act of 2005 (DRA) enacted on February 8, 2006.  (Pub. L. No. 109-171).  Section 
6036 of the DRA, Improved Enforcement of Documentation Requirements, creates a new 
subsection 1903(x) of the Social Security Act (the Act) that requires individuals claiming U.S. 
citizenship to provide satisfactory documentary evidence of citizenship or nationality when 
initially applying for Medicaid or upon a recipients first Medicaid redetermination on or after 
July 1, 2006. 
 
Prior to enactment of this provision, in order for an individual to qualify for Medicaid, the 
applicant had to declare under penalty of perjury (under section 1137(d)(1)(A)) that he/she is a 
national or citizen of the United States, and, if not a citizen or national of the United States, that 
the individual is in a satisfactory immigration status.  Individuals who declared they were 
citizens did not have to do anything else to support that claim, although some States did require 
documentary evidence of such a claim.  However, the individuals who declared they were aliens 
in a satisfactory immigration status were required in every State to provide documentary 
evidence of that claim.  The new provision under Section 6036 effectively requires that the State 
obtain satisfactory documentation of a declaration of citizenship.  Self-attestation of citizenship 
and identity is no longer an acceptable practice.  The provisions of section 6036 do not affect 
individuals who have declared they are aliens in a satisfactory immigration status.  As with other 
Medicaid program requirements, States must implement an effective process for assuring 
compliance with documentation of citizenship in order to obtain Federal matching funds, and 
effective compliance will be part of Medicaid program integrity monitoring. 
 
Section 6036 specifies certain forms of acceptable evidence of citizenship or nationality and 
identity that are effective July 1, 2006.  We have marked documents listed in section 6036 with 
asterisks *** in the charts that follow. The statute also provides the Secretary with authority to 
specify, by regulation, other documents that provide proof and a reliable means of 
documentation of United States citizenship or nationality and personal identity.  CMS plans to 
publish regulations that would exercise this authority. CMS has included documents it is, at 
present, considering utilizing in its upcoming rulemaking in the charts that follow.  
 
A.   Establishing United States (U.S.) Citizenship and Identity 
Note:  State Medicaid Agency determinations of citizenship are not binding on other federal 
agencies for any other purposes.  Page 2  State Medicaid Director     
 
To establish U.S. citizenship the document must show:  
  A U.S. place of birth, or  
  That the person is a U.S. citizen.  
 
Note: Children born in the U.S. to foreign sovereigns or diplomatic officers are not U.S. citizens.  
 
To establish identity a document must show:    
  Evidence that provides identifying information that relates to the person named on the 
document. 
 
B.   Documents Establishing U.S. Citizenship and Identity  
The following Charts list acceptable evidence of U.S. citizenship and/or identity.  Charts 1-4 
address citizenship and Charts 1 and 5 address identity.  If an individual presents documents 
from Chart 1 no other information would be required.  If an individual presents documents from 
Charts 2-4, then an identity document from Chart 5 must also be presented.  Charts 1-4 establish 
a hierarchy of reliability of citizenship documents and the following instructions specify when a 
document of lesser reliability may be accepted by the State.  The State would make the decision 
whether documents of a given level of reliability are available.  See discussion of additional 
documents for use when a child is 16 years of age or younger. 
 
1.   Primary Documents to Establish Both U.S. Citizenship and Identity (See Chart 1) 
Primary evidence of citizenship and identity is documentary evidence of the highest reliability 
that conclusively establishes that the person is a U.S. citizen.  In general, obtain primary 
evidence of citizenship and identity before using secondary evidence. Accept any of the 
documents listed in this Chart as primary evidence of both U.S. citizenship and identity if the 
document meets the listed criteria and there is nothing indicating the person is not a U.S. citizen 
(e.g., lost U.S. citizenship). 
 
Note:  Persons born in American Samoa (including Swains Island) are generally U.S. non-
citizen nationals.  References in this guidance to citizens should be read as references to non-
citizen nationals with respect to these persons.  There is no difference in terms of Medicaid 
eligibility. 
 
Note:  References to documents issued by the Department of Homeland Security (DHS) include 
documents issued by its predecessor, the Immigration and Naturalization Services (INS).  On 
March 1, 2003, the former INS became part of DHS, and its naturalization function was assumed 
by U.S. Citizenship and Immigration Services (USCIS) within DHS.  However, even documents 
issued after this date may bear INS legends. 
 
Applicants or recipients born outside the U.S. who were not citizens at birth must submit a 
document listed under primary evidence of U.S. citizenship.  Page 3  State Medicaid Director     
 
Chart 1 
Primary  Documents  Explanation 
***U.S. passport  The Department of State issues this. A U.S. passport does not have to 
be currently valid to be accepted as evidence of U.S. citizenship, as 
long as it was originally issued without limitation.   
 
Note: Spouses and children were sometimes included on one passport 
through 1980. U.S. passports issued after 1980 show only one person. 
Consequently, the citizenship and identity of the included person can be 
established when one of these passports is presented. 
 
Exception: Do not accept any passport as evidence of U.S. citizenship 
when it was issued with a limitation. However, such a passport may be 
used as proof of identity. 
***Certificate of  Department of Homeland Security issues for naturalization.   
Naturalization (N-550 
or N-570) 
***Certificate of  Department of Homeland Security issues certificates of citizenship to 
Citizenship   individuals who derive citizenship through a parent.    
(N-560 or N-561)  
 
2.  Secondary Documents to Establish U.S. Citizenship (See Chart 2) 
Secondary evidence of citizenship is documentary evidence of satisfactory reliability that is used 
when primary evidence of citizenship is not available.  In addition, a second document 
establishing identity MUST also be presented as described in item 5, Evidence of Identity.   
 
Available evidence is evidence that exists and can be obtained within your States reasonable 
opportunity period.  The reasonable opportunity period is discussed under the heading 
Reasonable Opportunity. 
 
Accept any of the documents listed in this Chart as secondary evidence of U.S. citizenship if the 
document meets the listed criteria and there is nothing indicating the person is not a U.S. citizen 
(e.g., lost U.S. citizenship). 
 
Applicants or recipients born outside the U.S. must submit a document listed under primary 
evidence of U.S. citizenship.  Page 4  State Medicaid Director     
Chart 2 
Secondary Documents  Explanation 
A U.S. public birth record  The birth record document may be issued by the State, 
showing birth in:   Commonwealth, territory or local jurisdiction. It must have been 
  one of the 50 U.S.  issued before the person was 5 years of age. 
States;    
An amended birth record document that is amended after 5 years 
  District of 
of age is considered fourth level evidence of citizenship.  
Columbia;  
 
  American Samoa 
Note: If the document shows the individual was born in Puerto 
  Swains Island  Rico, the Virgin Islands of the U.S., or the Northern Mariana 
  *Puerto Rico (if  Islands before these areas became part of the U.S., the individual 
born on or after  may be a collectively naturalized citizen. Collective naturalization 
January 13, 1941);  occurred on certain dates listed for each of the territories.  *See 
additional requirements for Collective Naturalization. 
  *Virgin Islands of 
the U.S. (on or after 
January 17, 1917) 
or 
  *Northern Mariana 
Islands (after 
November 4, 1986 
(NMI local time)) 
  *Guam (on or after 
April 10, 1899 
***Certification of Report  The Department of State issues a DS-1350 to U.S. citizens in the 
of Birth (DS-1350)   U.S. who were born outside the U.S. and acquired U.S. citizenship 
at birth, based on the information shown on the FS-240. When the 
birth was recorded as a Consular Report of Birth (FS-240), 
certified copies of the Certification of Report of Birth Abroad 
(DS-1350) can be issued by the Department of State in 
Washington, D.C. The DS-1350 contains the same information as 
that on the current version of Consular Report of Birth FS-240. 
The DS-1350 is not issued outside the U.S.  
***Consular Report of  The Department of State consular office prepares and issues this. 
Birth Abroad of a Citizen  A Consular Report of Birth can be prepared only at an American 
of the United States of  consular office overseas while the child is under the age of 18. 
America (FS-240)   Children born outside the U.S. to U.S. military personnel usually 
have one of these.  
***Certification of Birth  Before November 1, 1990, Department of State consulates also 
Abroad (FS-545)   issued Form FS-545 along with the prior version of the FS-240. In 
1990, U.S. consulates ceased to issue Form FS-545. Treat an FS-
545 the same as the DS-1350. 
***United States Citizen  INS issued the I-179 from 1960 until 1973. It revised the form and 
Identification Card (I-197)  renumbered it as Form I-197. INS issued the I-197 from 1973 until  Page 5  State Medicaid Director     
Secondary Documents  Explanation 
or the prior version I-179  April 7, 1983. INS issued Form I-179 and I-197 to naturalized 
(Section 6036 referred to  U.S. citizens living near the Canadian or Mexican border who 
these documents in error as  needed it for frequent border crossings. Although neither form is 
an I-97.)   currently issued, either form that was previously issued is still 
valid. 
American Indian Card (I- DHS issues this card to identify a member of the Texas Band of 
872)  Kickapoos living near the U.S./Mexican border. A classification 
code KIC and a statement on the back denote U.S. citizenship.  
Northern Mariana Card (I- The former Immigration and Naturalization Service (INS) issued 
873)   the I-873 to a collectively naturalized citizen of the U.S. who was 
born in the NMI before November 4, 1986. The card is no longer 
issued, but those previously issued are still valid.  
Final adoption decree  The adoption decree must show the childs name and U.S. place of 
birth.  In situations where an adoption is not finalized and the 
State in which the child was born will not release a birth 
certificate prior to final adoption, a statement from a State 
approved adoption agency that shows the childs name and U.S. 
place of birth is acceptable.  The adoption agency must state in the 
certification that the source of the place of birth information is an 
original birth certificate. 
Evidence of civil service  The document must show employment by the U.S. government 
employment by the U.S.  before June 1, 1976 
government 
Official Military record of  The document must show a U.S. place of birth (for example a DD-
service  214 or similar official document showing a U.S. place of birth) 
 
3.  Third Level Documents to Establish U.S. Citizenship (See Chart 3) 
Third level evidence of U.S. citizenship is documentary evidence of satisfactory reliability that is 
used when neither primary nor secondary evidence of citizenship is available.  Third level 
evidence may be used ONLY when primary evidence cannot be obtained within the States 
reasonable opportunity period (see reasonable opportunity discussion below), secondary 
evidence does not exist or cannot be obtained, and the applicant or recipient alleges being born 
in the U.S.  In addition, a second document establishing identity MUST be presented as 
described in item 5, Evidence of Identity. 
 
Accept any of the documents listed in this Chart as third level evidence of U.S. citizenship if the 
document meets the listed criteria, the applicant alleges birth in the U.S., and there is nothing 
indicating the person is not a U.S. citizen (e.g., lost U.S. citizenship). 
 
Third level evidence is generally a non-government document established for a reason other than 
to establish U.S. citizenship and showing a U.S. place of birth. The place of birth on the non-
government document and the application must agree. 
  Page 6  State Medicaid Director     
Chart 3 
Third Level Documents  Explanation  
Extract of hospital record  Do not accept a souvenir birth certificate issued by the hospital. 
on hospital letterhead   
established at the time of  Note:  For children under 16 the document must have been created 
the persons birth and was  near the time of birth or 5 years before the date of application.  
created at least 5 years 
before the initial 
application date and 
indicates a U.S. place of 
birth  
Life or health or other  Life or health insurance records may show biographical 
insurance record showing a  information for the person including place of birth; the record can 
U.S. place of birth and was  be used to establish U.S. citizenship when it shows a U.S. place of 
created at least 5 years  birth. 
before the initial   
application date  
 
4.  Fourth Level Documents to Establish U.S. Citizenship (See Chart 4) 
Fourth level evidence of U.S. citizenship is documentary evidence of the lowest reliability.  
Fourth level evidence should ONLY be used in the rarest of circumstances.  This level of 
evidence is used ONLY when primary evidence is not available, both secondary and third level 
evidence do not exist or cannot be obtained within the States reasonable opportunity period, and 
the applicant alleges a U.S. place of birth.  In addition, a second document establishing identity 
MUST be presented as described in item 5, Evidence of Identity.  Available evidence is evidence 
that can be obtained within the States reasonable opportunity period as discussed below.  
 
Accept any of the documents listed in this Chart as fourth level evidence of U.S. citizenship if 
the document meets the listed criteria, the applicant alleges U.S. citizenship, and there is nothing 
indicating the person is not a U.S. citizen (e.g., lost U.S. citizenship). In addition, a second 
document establishing identity must be presented. 
 
Fourth level evidence, as described below, consists of documents established for a reason other 
than to establish U.S. citizenship and showing a U.S. place of birth.  The U.S. place of birth on 
the document and the application must agree.  The written affidavit described in this Chart may 
be used only when the State is unable to secure evidence of citizenship listed in any other Chart.  
  
Chart 4 
Fourth Level Documents  Explanation  
Federal or State census  The census record must also show the applicants age. 
record showing U.S.   
citizenship or a U.S. place  Note: Census records from 1900 through 1950 contain certain 
of birth (Generally for  citizenship information.  To secure this information the 
persons born 1900 through  applicant, recipient or State should complete a Form BC-600, 
1950).  Application for Search of Census Records for Proof of Age.  Add  Page 7  State Medicaid Director     
Fourth Level Documents  Explanation  
in the remarks portion U.S. citizenship data requested.  Also 
add that the purpose is for Medicaid eligibility.  This form 
requires a fee. 
Other document as listed in  This document must be one of the following and show a U.S. 
the explanation that was  place of birth:  
created at least 5 years    Seneca Indian tribal census record 
before the application for    Bureau of Indian Affairs tribal census records of the Navaho 
Medicaid  Indians 
  U.S. State Vital Statistics official notification of birth 
registration 
  An amended U.S. public birth record that is amended more 
than 5 years after the persons birth 
  Statement signed by the physician or midwife who was in 
attendance at the time of birth 
Institutional admission  Admission papers generally show biographical information for 
papers from a nursing  the person including place of birth; the record can be used to 
home, skilled nursing care  establish U.S. citizenship when it shows a U.S. place of birth. 
facility or other institution 
and was created at least 5 
years before the initial 
application date and 
indicates a U.S. place of 
birth  
Medical (clinic, doctor, or  Medical records generally show biographical information for the 
hospital) record and was  person including place of birth; the record can be used to 
created at least 5 years  establish U.S. citizenship when it shows a U.S. place of birth. 
before the initial   
application date and  Note: An immunization record is not considered a medical record 
indicates a U.S. place of  for purposes of establishing U.S. citizenship. 
birth    
Note:  For children under 16 the document must have been 
created near the time of birth or 5 years before the date of 
application. 
Written Affidavit  Affidavits should ONLY be used in rare circumstances.  An 
affidavit by at least two individuals of whom one is not related to 
the applicant/recipient and who have personal knowledge of the 
event(s) establishing the applicants or recipients claim of 
citizenship.  The person(s) making the affidavit must be able to 
provide proof of his/her own citizenship and identity for the 
affidavit to be accepted.  If the affiant has information which 
explains why documentary evidence establishing the applicants 
claim of citizenship does not exist or cannot be readily obtained, 
the affidavit should contain this information as well.  It must also 
be signed under penalty of perjury by the person making the  Page 8  State Medicaid Director     
Fourth Level Documents  Explanation  
affidavit.  A second affidavit from the applicant/recipient or 
other knowledgeable individual explaining why documentary 
evidence does not exist or cannot be readily obtained must also 
be requested.   
 
5.   Evidence of Identity (See Chart 5) 
Section 1903(x) provides that identity must be established.  When primary evidence of 
citizenship described in number 1 above is not available, a document from the lists in number 2 
through 4 may be presented if accompanied by an identity document from this list. 
 
Chart 5 
Documents to Establish  Explanation  
Identity 
Certificate of Degree of  Acceptable if the document carries a photograph of the applicant 
Indian Blood, or other U.S.  or recipient, or has other personal identifying information relating 
American Indian/Alaska  to the individual. 
Native tribal document.   
 
***Any identity document  Use 8 CFR 274a.2(b)(1)(v)(B)(1).  This section includes the 
described in section  following acceptable documents for Medicaid purposes: 
274A(b)(1)(D) of the    drivers license issued by State or Territory either with a 
Immigration and Nationality  photograph of the individual or other identifying 
Act  information of the individual such as name, age, sex, race, 
height, weight or eye color. 
  School identification card with a photograph of the 
individual 
  U.S. military card or draft record 
  Identification card issued by the Federal, State, or local 
government with the same information included on 
drivers licenses 
  Military dependents identification card 
  Native American Tribal document 
  U.S. Coast Guard Merchant Mariner card   
 
Note:  For children under 16, school records may include nursery 
or daycare records.  If none of the above documents in the 
preceding charts are available, an affidavit may be used.  An 
affidavit is only acceptable if it is signed under penalty of perjury 
by a parent or guardian stating the date and place of the birth of 
the child and cannot be used if an affidavit for citizenship was 
provided. 
 
Exception:  Do not accept a voters registration card or Canadian 
drivers license as listed in 8 CFR 274a.2(b)(1)(v)(B)(1).    Page 9  State Medicaid Director     
 
Collective Naturalization 
 
The following will establish U.S. citizenship for collectively naturalized individuals: 
 
Puerto Rico: 
  Evidence of birth in Puerto Rico on or after April 11, 1899 and the applicant's statement 
that he or she was residing in the U.S., a U.S. possession or Puerto Rico on January 13, 
1941; or 
  Evidence that the applicant was a Puerto Rican citizen and the applicant's statement that 
he or she was residing in Puerto Rico on March 1, 1917 and that he or she did not take an 
oath of allegiance to Spain. 
U.S. Virgin Islands: 
  Evidence of birth in the U.S. Virgin Islands, and the applicant's statement of residence in 
the U.S., a U.S. possession or the U.S. Virgin Islands on February 25, 1927; 
  The applicant's statement indicating resident in the U.S. Virgin Islands as a Danish 
citizen on January 17, 1917 and residence in the U.S., a U.S. possession or the U.S. 
Virgin Islands on February 25, 1927, and that he or she did not make a declaration to 
maintain Danish citizenship; or 
  Evidence of birth in the U.S. Virgin Islands and the applicant's statement indicating 
residence in the U.S., a U.S. possession or territory or the Canal Zone on June 28, 1932. 
Northern Mariana Islands (NMI) (formerly part of the Trust Territory of the Pacific Islands 
(TTPI)): 
  Evidence of birth in the NMI, TTPI citizenship and residence in the NMI, the U.S., or a 
U.S. territory or possession on November 3, 1986 NMI local time) and the applicant's 
statement that he or she did not owe allegiance to a foreign state on November 4, 1986 
(NMI local time); 
  Evidence of TTPI citizenship, continuous residence in the NMI since before November 3, 
1981 (NMI local time), voter registration prior to January 1, 1975 and the applicant's 
statement that he or she did not owe allegiance to a foreign state on November 4, 1986 
(NMI local time); or 
  Evidence of continuous domicile in the NMI since before January 1, 1974 and the 
applicant's statement that he or she did not owe allegiance to a foreign state on November 
4, 1986 (NMI local time). 
 
Note: If a person entered the NMI as a nonimmigrant and lived in the NMI since January 1, 
1974, this does not constitute continuous domicile and the individual is not a U.S. citizen. 
 
Treatment of Title IV-E Children and Individuals Receiving Services through Medicaid 
Section 1115 Demonstrations 
Title IV-E children receiving Medicaid must have in their Medicaid file a declaration of 
citizenship or satisfactory immigration status and documentary evidence of the citizenship or 
satisfactory immigration status claimed on the declaration.  
 
Individuals who are receiving benefits under a section 1115 demonstration project approved 
under Title XI authority are subject to this provision.  This includes expansion eligible 
individuals under statewide section 1115 demonstrations and family planning demonstrations. 
  Page 10  State Medicaid Director     
Drivers License Documentation to Establish Both Citizenship and Identification 
 
Section 6036(a)(3)(B)(iv) of the DRA permits the use of a valid State-issued drivers license or 
other identity document described in Section 274A(b)(1)(D) of the Immigration and Nationality 
Act, but only if the State issuing the license or such document requires proof of United States 
citizenship before issuance of such license or document or obtains a social security number from 
the applicant and verifies before certification that such number is valid and assigned to the 
applicant who is a citizen.  CMS is not currently aware that any State has these processes in 
place at this time.  Therefore, until such time that a State has this requirement in place this 
documentation may not be accepted.  
  
Effective Date 
For new Medicaid applicants or for currently enrolled individuals, the State must obtain evidence 
of citizenship at the time of application or at the time of the first redetermination occurring on or 
after July 1, 2006.  Recipients will need to provide such documentation only once unless doubt is 
cast on the situation because once citizenship is established it is a circumstance not likely to 
change.   
 
Reasonable Opportunity 
Beginning July 1, 2006 self attestation of citizenship by applicants or recipients will no longer be 
acceptable.  Therefore, at the time of application or redetermination, the State must give an 
applicant or recipient, who has signed a declaration required by section 1137(d) of the Act and 
claims to be a citizen, a reasonable opportunity to present documents establishing U.S. 
citizenship or nationality and identity.  For individuals who are already Medicaid recipients, such 
individuals remain eligible until determined ineligible as required by Federal regulations at 42 
CFR 435.930.  A determination terminating eligibility may be made only after the recipient has 
been given a reasonable opportunity to present evidence of citizenship or the State determines 
the individual has not made a good faith effort to present satisfactory documentary evidence of 
citizenship.  By contrast, applicants for Medicaid (who are not currently receiving Medicaid), 
should not be made eligible until they have presented the required evidence.  This is no different 
than current policy regarding information which an initial applicant must submit in order for the 
State to make an eligibility determination. 
 
The reasonable opportunity period should be consistent with the States administrative 
requirements such that the State does not exceed the time limits established in Federal 
regulations for timely determination of eligibility in 42 CFR 435.911. The regulations permit 
exceptions from the time limits when an applicant or recipient in good faith tries to present 
documentation, but is unable to do so because the documents are not available.  In such cases, 
the State should assist the individual in securing evidence of citizenship.  In these situations, 
States may use matches with other agencies to assist applicants or recipients to meet the 
requirements of the law.  For example, States already receive the State Data Exchange (SDX). 
Therefore, a match of Medicaid applicants or recipients to the SDX that shows the individual has 
proved citizenship would satisfy the documentation requirement of this provision with respect to 
SSI recipients.  An SSI recipients citizenship status can be found in the Alien Indicator Code at 
position 578 on the SDX.  The BENDEX record is an extract of the Master Beneficiary Record 
and it does not currently house any data on U.S. citizenship or alien status; therefore, this system 
may not be utilized.  States may use matches with State vital statistics agencies to assist 
applicants or recipients to document citizenship.  Page 11  State Medicaid Director     
 
Applicants or Recipients Needing Assistance 
If the applicant or recipient is homeless, an amnesia victim, mentally impaired, or physically 
incapacitated and lacks someone who can act for the individual, and cannot provide evidence of 
U.S. citizenship or identity, the State should assist the applicant or recipient to document U.S. 
citizenship and identity. 
 
State Processes and Best Practices 
  All documents must be either originals or copies certified by the issuing agency.  Copies 
or notarized copies may not be accepted. 
  States must maintain copies in the case record or data base and make available for 
compliance audits. 
  States may permit applicants and recipients to submit such documentary evidence 
without appearing in person at a Medicaid office. 
  If documents are determined to be inconsistent with pre-existing information, are 
counterfeit, or altered, States should investigate for potential fraud and abuse, including 
but not limited to, referral to the appropriate State and Federal law enforcement agencies. 
  Presentation of documentary evidence of citizenship is a one time activity; once a 
persons citizenship is documented and recorded in a State database subsequent changes 
in eligibility should not require repeating the documentation of citizenship unless later 
evidence raises a question of the persons citizenship.  The State need only check its 
databases to verify that the individual already established citizenship. 
  A number of States have long required their applicants to document citizenship.  New 
York, New Hampshire, and Montana report that they have, as part of the Medicaid 
eligibility process, required documentation of citizenship for many years without undue 
hardship to either applicants or the State.  New York and New Hampshire have published 
guidelines for documenting U.S. citizenship that generally mirror the list of acceptable 
documents contained in this letter.  Any State that currently has a process in place to 
document citizenship should review this State Medicaid Directors letter and modify their 
process, as appropriate, to ensure conformity with Section 6036 of the Deficit Reduction 
Act of 2005. 
 
Denial, Termination, Notice and Appeals 
The enactment of section 6036 does not change any CMS policies regarding the taking and 
processing of applications for Medicaid except the new requirement for presentation of 
documentary evidence of citizenship.  Thus, the requirement that determination of Medicaid 
eligibility be performed in a manner consistent with proper and efficient administration continues 
to apply.  Likewise, the regulations at 42 CFR 435.902, 435.910(e), 435.912, 435.919 and 
435.920 continue to apply when securing from applicants and recipients documentary evidence 
of citizenship and identity.  Thus, States are not obligated to make or keep eligible any individual 
who fails to cooperate with the requirement to present documentary evidence of citizenship and 
identity.  Failure to provide this information is no different than the failure to provide any other 
information which is material to the eligibility determination.   
 
An applicant or recipient who fails to cooperate with the State in presenting documentary 
evidence of citizenship may be denied or terminated.   Failure to cooperate consists of failure by 
an applicant recipient or that individuals representative, after being notified, to take a required 
action.  Notice and appeal rights and adequate and timely notice must be given to beneficiaries if  Page 12  State Medicaid Director     
the State denies or terminates an individual for failure to cooperate with the requirement to 
provide documentary evidence of citizenship.  In the case of recipients, the notice must be in 
advance.   
 
Federal Financial Participation (FFP) for Administrative Expenditures 
CMS will provide FFP for State expenditures to carry out the provisions of section 1903(x) at the 
match rate for program administration.  
 
Compliance 
FFP will not be available if a State does not require applicants and recipients to provide 
satisfactory documentary evidence of citizenship, or does not secure such documentary evidence 
which includes the responsibility to accept only authentic documents on or after July 1, 2006.  
The Centers for Medicare & Medicaid Services (CMS) will review implementation of section 
6036 to determine whether claims for FFP for services provided to citizens should be deferred or 
disallowed.  Additionally, CMS will monitor the extent to which the State is using primary 
evidence to establish both citizenship and identity and will require corrective action to ensure the 
most reliable evidence is routinely being obtained. 
 
CMS requires that as a check against fraud, using currently available automated capabilities, 
States will conduct a match of the applications name against the corresponding Social Security 
number that was provided.  In addition, CMS, in cooperation with other agencies of the federal 
government, is establishing automated capabilities through which a State would be able to verify 
citizenship and identity of Medicaid applicants.  When these capabilities become available, 
States will be required to match files for individuals who used third or fourth tier documents to 
verify citizenship and fifth level documents to verify identity, and CMS will make available to 
States necessary information in this regard in a future State Medicaid Directors Letter.  States 
are hereby directed to ensure that all case records within this category will be so identified and 
made available to conduct these automated matches.  CMS may also require States to match files 
for individuals who used first or second level documents to verify citizenship as well.  CMS may 
provide further guidance to Sates with respect to actions required in a case of a negative match. 
 
Outreach Plan 
CMS will implement an outreach plan to explain the requirements of section 1903(x).  In 
addition, we will place on our website tools States may use in conducting similar outreach.  
Meanwhile, we encourage States to alert your Medicaid beneficiaries and potential applicants as 
soon as possible about the requirement to provide acceptable documentary evidence of 
citizenship upon Medicaid application or upon initial redetermination and how the requirements 
may be met.  We encourage States to work with organizations and applicants in meeting this 
requirement.  Also, we encourage States to begin reviewing  files and procedures to determine 
what information is currently on hand to minimize the workload associated with this requirement 
beginning July 1, 2006.  We are confident that your implementing procedures will assure 
compliance with this requirement.  Page 13  State Medicaid Director     
Questions 
Questions regarding this provision may be directed to Jean Sheil, Director, Family and 
Childrens Health Programs Group at 7500 Security Blvd., Mail Stop S2-01-16, Baltimore, 
Maryland 21244-1850. 
 
            Sincerely, 
 
  /s/ 
 
Dennis G. Smith 
Director 
 
Enclosure 
 
cc:   
 
CMS Regional Administrators 
 
CMS Associate Regional Administrators 
    for Medicaid and State Operations 
 
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