DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland   21244-1850 
SHO # 21-005 
Re:  Medicaid Eligibility for COFA 
Migrants 
October 18, 2021 
Dear State Health Official: 
The purpose of this letter is to provide policy and operational guidance to states to implement the 
extension of Medicaid eligibility to the citizens of the Freely Associated States (FAS) living in the 
United States under the Compacts of Free Association (COFA).  This extension was enacted on 
December 27, 2020 in section 208 of Division CC of the Consolidated Appropriations Act, 2021 
(P.L. 116-260)1 (CAA).  Effective December 27, 2020, states and the District of Columbia are 
required to provide coverage for all Medicaid benefits, including benefits provided through the 
Medicare Savings Programs2 and other eligibility groups with limited services, included under the 
state plan (full Medicaid benefits) to COFA migrants who otherwise meet all of the eligibility 
requirements in the state plan.  Territories have the option to cover COFA migrants for full Medicaid 
benefits in their programs.  The CAA does not address coverage of COFA migrants under a separate 
Childrens Health Insurance Program (CHIP). 
This letter addresses the following topics: 
 Extension of Medicaid eligibility to COFA migrants
 Changes to the Federal Exchange eligibility and enrollment platform (Federal platform) and
Federal Data Services Hub to implement the change to COFA migrants Medicaid eligibility
 Operational considerations for states
 Applicable Federal Medical Assistance Percentage (FMAP)
 Territory considerations
1 https://www.congress.gov/116/bills/hr133/BILLS-116hr133enr.pdf. 
2 The Medicare Savings Programs (MSPs) is a Medicaid program under which a state Medicaid agency provides 
coverage for the Medicare premiums and cost-sharing incurred by certain low-income Medicare beneficiaries.  The extent 
of this coverage varies depending on the amount of income and resources an MSP applicant has.  For more detailed 
information on eligibility categories and benefits, see https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-
and-Medicaid-Coordination/Medicare-Medicaid-Coordination-
Office/Downloads/MedicareMedicaidEnrolleeCategories.pdf. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, 
unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding 
existing requirements under the law.  Page 2  State Health Official 
 
Background 
COFAs are agreements between the United States and the three Pacific Island sovereign states of the 
Federated States of Micronesia (FSM), the Republic of the Marshall Islands (RMI), and the Republic 
of Palaucollectively known as FAS.  COFA migrants are classified by the Department of 
Homeland Security as nonimmigrants and are authorized to be employed in the United States.3 
 
Since the enactment of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 
(PRWORA; P.L. 104-193) on August 22, 1996, COFA migrants have not been included in the 
definition of qualified non-citizens4 (QNCs) and thus generally have not been eligible for full 
Medicaid benefits.5  Following enactment of PRWORA, COFA migrants who met all other eligibility 
requirements in the Medicaid state plan have been eligible only for services that are necessary for the 
treatment of an emergency medical condition (emergency Medicaid).6 
  
In addition, COFA migrants who are lawfully present7 and under age 21 or pregnant have been 
entitled to full state plan benefits under Medicaid and CHIP, if they meet eligibility requirements, in 
states and territories that elected to cover lawfully residing non-citizens under sections 1903(v)(4)(A) 
and 2107(e)(1)(O) of the Social Security Act (the Act).  This option, established by section 214 of the 
Childrens Health Insurance Program Reauthorization Act of 2009 (CHIPRA; P.L. 111-3), often is 
referred to as the CHIPRA 214 option.  COFA migrants, who generally are lawfully present as 
defined at 45 C.F.R.  152.2, also have been able to enroll in a Qualified Health Plan and can receive 
advance payments of the premium tax credit (APTC) through a Federal Exchange or a State-Based 
Exchange if the individual meets other applicable eligibility criteria for enrollment and for APTC.8 
 
Effective December 27, 2020, Division CC, Title II, section 208 of the CAA requires states to 
provide full Medicaid benefits to COFA migrants who are residing in one of the fifty states or the 
District of Columbia without a five-year waiting period.9  Under the CAA, COFA migrants are 
defined as QNCs and exempted from the five-year waiting period for purposes of Medicaid eligibility 
only.10 
                                                 
3 See 8 C.F.R.  274a.12(a)(8).  See also https://save.uscis.gov/web/media/resourcesContents/CFA_MIS.pdf, 
https://www.uscis.gov/sites/default/files/document/fact-sheets/FactSheetVerifyFASCitizens.pdf,  
https://www.uscis.gov/sites/default/files/document/fact-sheets/FactSheet-Status_of_Citizens_of_Palau.pdf  
4 8 U.S.C.  1641, see also, 42 C.F.R.  435.4. 
5 For the purpose of this letter, full Medicaid benefits refers to all services covered for a given eligibility group beyond 
those needed to treat an emergency medical condition. Full Medicaid benefits include instances in which an individual is 
only eligible for eligibility groups with limited benefits, including the Medicare Savings Programs. 
6 See Section 1903(v)(2) and (v)(3) of the Act.  
7 See State Health Official Letter #10-006, #10-006, Medicaid and CHIP Coverage of Lawfully Residing Children and 
Pregnant Women, (issued July 1, 2010), available at https://www.medicaid.gov/federal-policy-
guidance/downloads/SHO10006.pdf; See also 8 C.F.R  274a.12(a)(8) and DHS USCIS Fact Sheets at FN 3. 
8 See 45 C.F.R.  152.2 and 45 C.F.R.  155.305; see also FN 3, for DHS regulations and additional information on 
COFA migrants immigration status. 
9 8 U.S.C.  1612(b)(2)(G), 8 U.S.C.  1613(b)(3). 
10 8 U.S.C.  1641(b)(8); 8 U.S.C.  1613(b)(3). 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, 
unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding 
existing requirements under the law.  Page 3  State Health Official 
 
  
Some COFA migrants can apply for adjustment of status to Lawful Permanent Resident (LPR or 
green card holder).11  After a COFA migrant adjusts to LPR status, states apply any other eligibility 
requirements that would apply to other LPRs in the states Medicaid program, including the five-year 
waiting period under 8 U.S.C. 1613(a), unless the individual meets one of the other exemptions 
from the five-year waiting period listed in 8 U.S.C.  1613(b).  A COFA migrant who adjusts to LPR 
status could be a qualified non-citizen as early as December 27, 2020 for purposes of calculating the 
five-year waiting period for Medicaid, in accordance with 8 U.S.C.  1641(b)(8).  For example, a 
COFA migrant living in the United States since January 1, 2021 who adjusts to LPR status on 
January 1, 2025, after four years of living in the U.S. as a COFA migrant, would have one year 
remaining of the five-year waiting period (i.e., until January 1, 2026) for Medicaid purposes.  A 
COFA migrant living in the United States since January 1, 2019 who adjusts to LPR status on 
January 1, 2025 would have just under one year remaining of the five-year waiting period (i.e., until 
December 27, 2025) for Medicaid purposes.  If a COFA migrant adjusted to LPR status prior to 
December 27, 2020, the date for calculating the five-year waiting period would begin on the date 
such adjustment to LPR status was granted.  See 8 U.S.C. 1641(b)(1).  If the five-year waiting period 
applies and has not been met after the individual adjusts to LPR status, the individual would only be 
eligible for Medicaid payment for the treatment of an emergency medical condition, provided that all 
other eligibility requirements are met, unless the individual is under age 21 or a pregnant woman and 
the state has elected the option under CHIPRA 214 to cover all lawfully present pregnant women 
and/or individuals under age 21.  See 8 U.S.C.  1613(c)(2)(A).12 
 
Section 208 of the CAA provides an option for the U.S. Territories to provide full Medicaid benefits 
to COFA migrants who are lawfully residing in the territory.13  Importantly, the expenditures for 
medical assistance provided to a COFA migrant in a territory electing this option are not taken into 
account for purposes of the payment limits established under section 1108(f) and (g) of the Act.14 
 
Note that the CAA does not create a new Medicaid eligibility group for COFA migrants.  Rather, 
states must evaluate COFA migrants eligibility for coverage under all applicable eligibility groups 
covered under the state plan or section 1115 demonstration project, including limited benefit 
demonstrations such as family planning section 1115 demonstrations, and provide full Medicaid 
benefits for those who meet all eligibility requirements for Medicaid under the state plan or 
demonstration project. 
State Plan Submission  
                                                 
11 See https://www.uscis.gov/sites/default/files/document/fact-sheets/FactSheetVerifyFASCitizens.pdf, 
https://www.uscis.gov/sites/default/files/document/fact-sheets/SAVEfactsheetStatusofCitizensoftheRepublicofPalau.pdf 
12 A COFA migrant who adjusts to LPR status and is subject to the five-year waiting period and only eligible for 
Medicaid payment for the treatment of an emergency medical condition may also enroll in a Quaified Health Plan and 
receive advance payments of the premium tax credit through the Federal Exchange or a State-Based Exchange if the 
individual meets other applicable eligibility criteria for enrollment and for APTC. 
13 8 U.S.C.  1612(b)(2)(G). 
14 Section 1108(h) of the Act. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, 
unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding 
existing requirements under the law.  Page 4  State Health Official 
 
The 50 states and the District of Columbia are not required to submit a state plan amendment (SPA) 
to cover COFA migrants in their Medicaid programs.  Under section 208 of the CAA, COFA 
migrants are now included in the definition of QNCs and are exempt from the five-year waiting 
period.  Both the existing Citizenship and Non-Citizen Eligibility state plan Reviewable Unit (RU) 
submitted through MACPro and the S89 Non-Financial Eligibility-Citizenship and Non-Citizen 
state plan template submitted in MMDL contain an assurance that states are providing full Medicaid 
coverage to QNCs and are not applying the five-year waiting period to those exempt from that 
waiting period. 
  
Territories that want to cover COFA migrants for full Medicaid benefits must submit a SPA.  A 
territory may submit a SPA through MACPro or amend its paper state plan to add full Medicaid 
coverage for eligible COFA migrants.  Please see Appendix A for the suggested language territories 
may use when electing this option. 
 
As noted, the CAA does not address coverage of COFA migrants in a separate CHIP.  Therefore, the 
COFA Medicaid extension provided under the CAA does not extend to separate CHIP programs.  
However, states and territories can cover COFA migrants in a separate CHIP by adopting the 
CHIPRA 214 option, if they have not already done so, and can submit a SPA to elect this option.15  In 
order to elect to cover lawfully residing children and/or pregnant women in a separate CHIP under 
the CHIPRA 214 option, the state must also elect this option in its Medicaid program.  Also, the 
CHIPRA 214 option covers all lawfully residing children and/or pregnant women; states may not 
only cover a certain lawfully residing immigration status, such as COFA migrant status.16 
  
Federal Platform and Federal Data Services Hub  
The changes to the Medicaid eligibility of COFA migrants described in this letter have operational 
considerations for the eligibility determination, verification, and account transfer (AT) processes used 
by the Exchanges on the Federal platform and the Federal Data Services Hub (Hub).  CMS has 
made logic changes to the Federal platform so that Exchanges using the Federal platform accurately 
determine or assess Medicaid eligibility for COFA migrants, as applicable.  Exchanges that use the 
Federal platform will continue to determine COFA migrants ineligible for separate CHIP programs, 
unless otherwise eligible under a states election of CHIPRA 214 option.  CMS finalized changes 
to the Hub on June 13, 2021, such that the indicators returned to the Exchanges as well as states 
verifying immigration status through the Hub will support accurate identification of COFA migrants 
as QNCs not subject to the five-year waiting period for Medicaid purposes. (See more detail below on 
changes to the Hub).  Now that the Federal platform changes are completed, the Federal platform will 
send updated Hub indicators through the Outbound Account Transfer (AT) to states using the Federal 
platform, as applicable.   
                                                 
15 For more information on this option, see State Health Official letter #10-006, Medicaid and CHIP Coverage of 
Lawfully Residing Children and Pregnant Women, (issued July 1, 2010), available at 
https://www.medicaid.gov/federal-policy-guidance/downloads/SHO10006.pdf. 
16 See 2107(e)(1)(O) of the Act.   
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, 
unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding 
existing requirements under the law.  Page 5  State Health Official 
 
Modifications to the Hub are complete.  However, states may need to implement workarounds to 
assist in verifying and determining eligibility for COFA migrants if additional changes to state 
systems are needed, as described below and in more detail in the COFA Migrant presentation.17 
  
Operational Considerations for States 
Below we address a number of different operational considerations for states when implementing the 
extension of full Medicaid benefits to COFA migrants. 
  
Updates to Applications, Manuals and Related Materials 
The information individuals currently provide on states applications is likely sufficient to support 
Medicaid eligibility determinations for COFA migrants.  However, states may need to make modest 
changes to applications and other forms, including the addition of new instructions or help text, e.g., 
to include COFA migrants in a list of immigration statuses from which an applicant may choose.  
States are not required to submit an application SPA to CMS to make these modest changes.  Note 
that applications can only require information needed to determine applicants eligibility; thus, any 
changes to ensure COFA migrants accurately attest to their status must be limited to the applicants 
themselves.  The single, streamlined application used by Exchanges on the Federal platform does not 
need to be updated, as both its paper and online applications are designed to obtain needed 
attestations and immigration information from COFA migrants to verify their immigration status.  
States may also need to update policy and procedure manuals, call center scripts, and add language to 
their websites to reflect the extension of Medicaid eligibility to COFA migrants and notify applicants 
of the availability of written and oral language assistance.  In addition, updates to provider training 
materials and/or applications for Presumptive Eligibility (PE) and Hospital Presumptive Eligibility 
(HPE) may be needed to include COFA migrants in the list of non-citizen statuses that are exempt 
from the five-year waiting period and eligible for PE/HPE to the same extent as any other non-citizen 
with satisfactory immigration status who is exempt from the five-year waiting period. 
 
Verification of Immigration Status/SAVE 
States currently can verify immigration status with the Department of Homeland Securitys (DHS) 
Systematic Alien Verification for Entitlements (SAVE) program through three pathways.18 States can 
access SAVE through the Federal Data Services Hub (Hub) Verify Lawful Presence (VLP) v37 
Service,19 a direct web services user connection between a states eligibility system and SAVE, or 
SAVEs web-based interface, the Graphical User Interface (GUI).  States can also use a combination 
of the SAVE pathways.  States can establish new memoranda of agreement expeditiously, if needed, 
to use either the GUI or web services SAVE program pathway. 
  
Federal Data Services Hub (Hub) Verify Lawful Presence v37 Service 
                                                 
17 https://www.medicaid.gov/medicaid/eligibility/index.html. 
18 For additional information about COFA migrants and how to verify their immigration status, see USCISs resources at 
https://save.uscis.gov/web/media/resourcesContents/CFA_MIS.pdf, 
https://www.uscis.gov/sites/default/files/document/fact-sheets/FactSheetVerifyFASCitizens.pdf, 
https://www.uscis.gov/sites/default/files/document/fact-sheets/SAVEfactsheetStatusofCitizensoftheRepublicofPalau.pdf 
19 Verify Lawful Presence (VLP) v37 Business Service Definition (BSD).  
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, 
unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding 
existing requirements under the law.  Page 6  State Health Official 
 
The Hub is programmed to interpret immigration codes received from SAVE to determine whether 
an applicant is lawfully present, a Qualified Non-Citizen (QNC), subject to the five-year waiting 
period, and when applicable, whether the five-year waiting period has been met.  The Hub transmits 
to states both indicators reflecting QNC status and the applicability of the five-year waiting period 
and the underlying immigration codes for each non-citizen verified by the Hub.  States typically rely 
on the Hub indicators in verifying and determining immigrant eligibility for non-citizens.  Before 
June 13, 2021, the Hub did not interpret the immigration codes returned for COFA migrants to be 
indicative of eligibility for full Medicaid coverage.  As noted, CMS completed updates to the Hub 
logic on June 13, 2021, such that the Hub indicators will now reflect COFA migrants status as 
having a QNC status for Medicaid eligibility and not subject to the five-year waiting period.  If a 
COFA migrant adjusts status to LPR, then the COA code returned by SAVE will reflect their LPR 
status, rather than a COFA migrant status.  States that rely on the Hub indicators to determine 
whether a non-citizen has satisfactory immigration status no longer need to implement workarounds. 
  
See Appendix B for a summary of the Hub changes to verify COFA migrant immigration status.  
COFA migrant immigration status can be verified based on the Class of Admission (COA) codes, the 
Eligibility Statement Code (ESC)/Major Code, or Employment Authorization Document (EAD) 
Category codes that are part of verification responses received from SAVE.  States that can read and 
interpret the underlying immigration codes and other responses from SAVE can also use that 
information to verify and determine eligibility for COFA migrants. 
  
Direct Connections with SAVE and the GUI 
States that connect directly with SAVE through the GUI or web services can also verify COFA 
migrant immigration status by using the SAVE response and underlying codes.  GUI and web 
services users receive the same SAVE response COA and EAD codes as the Hub.  Web services 
users also receive the same Eligibility Statement Code/Major Code.  See Appendix B for details.  
 
Reminder:  If a state is not able to verify a COFA migrants satisfactory immigration status promptly 
and the individual has attested to eligible immigration status and is found otherwise eligible for 
Medicaid, a state is required to furnish benefits during the 90-day reasonable opportunity period 
(ROP), in accordance with section 1137(d) of the Act and 42 C.F.R.  435.956(b) of the Medicaid 
regulations, or such longer period provided by the state for non-citizens making a good faith effort to 
obtain documentation or where the agency itself needs more time to verify the individuals 
immigration status, consistent with 42 C.F.R.  435.956(b)(2)(ii)(B).  Before discontinuing ROP 
coverage, states must provide such individuals at least ten days advance notice. See 42 C.F.R  
431.211. 
 
Workarounds Prior to Systems Changes  
Because the requirement to provide full Medicaid benefits to otherwise-eligible COFA migrants was 
effective immediately with passage of the CAA on December 27, 2020, states must begin 
implementing the new requirement under Medicaid for COFA migrants as soon as possible. All states 
and territories should review the guidance in this letter to ensure that their policies and procedures are 
consistent with all applicable requirements concerning Medicaid eligibility for COFA migrants.  
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, 
unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding 
existing requirements under the law.  Page 7  State Health Official 
 
 
Because states may need to make systems changes to determine eligibility of COFA migrants, we 
have developed several strategies and workarounds that states can use until the necessary changes are 
implemented.  These strategies were explained in a technical assistance webinar for states, titled the 
COFA Medicaid Extension:  State Implementation, Short-term Workarounds and Outreach 
Strategies, conducted on May 4, 2021.  A link to the slide deck is found here 
(https://www.medicaid.gov/medicaid/eligibility/index.html).  States that have not yet implemented 
needed system changes should review these strategies and workarounds to ensure compliance with 
the requirement and prompt enrollment of eligible COFA migrants into Medicaid.  As described 
above, Hub indicator changes have now been completed so that COFA migrants are verified as 
qualified non-citizens not subject to the five-year waiting period.  
 
Eligibility Systems Upgrades and Funding 
We understand that states may need to make systems enhancements to their eligibility and enrollment 
system and/or their Medicaid Management Information System (MMIS) in order to consume Hub 
indicators or immigration codes and other responses from SAVE and enroll otherwise-eligible COFA 
migrants as QNCs who are not subject to the five-year waiting period and to ensure proper claiming 
and expenditure reporting on the CMS-64.  States that enroll otherwise-eligible non-citizens who are 
not in a satisfactory status for coverage limited to treatment for an emergency medical condition also 
may need to make edits to their MMIS to transition COFA migrant beneficiaries to full Medicaid 
benefits. 
  
Finally, COFA migrants with full Medicaid benefits under the CHIPRA 214 option who were 
reported in TMSIS as Code 2 Lawfully present under CHIPRA 214 or who had limited benefits 
only for treatment for emergency medical condition, coded as Code 3  Eligible only for payment 
for emergency services, should now be reported in TMSIS as Code 1 Qualified non-citizen.  
Systems changes may be needed to effectuate this change. 
 
Enhanced Federal Financial Participation (FFP) is available at a 90 percent FMAP for the design, 
development or installation of improvements to Medicaid eligibility determination systems, in 
accordance with applicable federal requirements, including changes related to determinations of 
eligibility to implement the COFA migrant eligibility policy changes.20  Seventy-five percent 
enhanced FFP is also available for operations of such systems, in accordance with applicable federal 
requirements.21  Receipt of these enhanced funds is conditioned upon states meeting a series of 
standards and conditions to ensure investments are efficient and effective.  To the extent these system 
costs are attributable to a states CHIP (Medicaid Expansion CHIP (MCHIP), or separate CHIP), 
cost-allocation methodologies set forth in 45 C.F.R. part 75 apply.  For the CHIP-funded portion of 
the cost, states can claim at a states CHIP EFMAP available under section 2105(b) of the Act.  CHIP 
                                                 
20 See section 1903(a)(3)(A)(i) and 42 C.F.R.  433.15(b)(3), 80 FR 75817-75843; https://www.medicaid.gov/state-
resource-center/faq-medicaid-and-chip-affordable-care-act-implementation/downloads/affordable-care-act-faq-enhanced-
funding-for-medicaid.pdf; https://www.medicaid.gov/federal-policy-guidance/downloads/SMD16004.pdf   
21 See section 1903(a)(3)(B) and 42 C.F.R.  433.15(b)(4). 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, 
unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding 
existing requirements under the law.  Page 8  State Health Official 
 
administrative funding is limited to 10 percent of either a states total computable allotments for a 
fiscal year or its total expenditures reported for a fiscal year, whichever is lower.22 
Other activities, such as COFA migrant eligibility policy development and outreach, may be claimed 
under Medicaid at the 50 percent administrative match, in accordance with regular claiming policies 
for such administrative activities.23 
  
Applicable Federal Medical Assistance Percentage  
Because COFA migrants are newly eligible for coverage, COFA migrants who are children up to age 
19 are considered targeted low-income children under sections 1905(u)(2)(B) and 2110(b) of the Act. 
These sections of the Act make expenditures for children who would not have been eligible for 
Medicaid under the rules in effect as of March 31, 1997 eligible for EFMAP.  As such, claims paid 
on behalf of children eligible under this new requirement may be matched at the title XXI EFMAP 
rate.  In general, expenditure claiming for COFA individuals follows existing federal requirements 
for Medicaid and CHIP expenditure claiming.  COFA-related expenditures for individuals enrolled in 
the states Medicaid program are claimed at the applicable FMAP under the Act on the CMS 64.9 
series of expenditure reporting forms in the Medicaid and Childrens Health Insurance Program 
Budget and Expenditure System (MBES/CBES) and are funded by Medicaid.  COFA-related 
expenditures for individuals enrolled in the states MCHIP program under section 1905(u)(2) of the 
Act (including COFA migrants who are children up to age 19) are claimed at the states EFMAP on 
the CMS 64.21U series of expenditure reporting forms and are funded by title XXI CHIP Allotments.  
As applicable for all MCHIP expenditures, under section 115 of CHIPRA, states continue to have the 
option to claim their MCHIP expenditures at the regular FMAP funded by Medicaid.24  
 
Territory Considerations 
As noted, providing coverage to COFA migrants for a U.S. Territory is an option.25  A territory that 
wishes to provide Medicaid coverage to COFA migrants must submit a SPA to CMS.  See sample 
SPA language in Appendix A.  The territorys regular FMAP will apply to coverage of COFA 
migrants.  However, expenditures for COFA migrants are not taken into account for purposes of the 
payment limits for territories established under section 1108(f) and (g) of the Act.26  There are no 
changes for territories that cover lawfully residing children and pregnant women in CHIP under the 
CHIPRA 214 option.  Territories continue to receive the appropriate CHIP enhanced FMAP provided 
under sections 1905(b) and 2105(b) of the Act for COFA migrant children eligible for Medicaid and 
CHIP due to a territorys adoption of the CHIPRA 214 option. 
 
Closing 
                                                 
22 See 42 C.F.R.  457.618(e)(1). 
23  See section 1903(a)(7) and 42 C.F.R.  433.15(b)(7). 
24 See https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/SHO10005_12.pdf for match rate 
options provided under section 115 of CHIPRA. 
25 See 8 U.S.C.  1612(b)(2)(G) 
26 See 42 U.S.C.  1308(h) 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, 
unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding 
existing requirements under the law.  Page 9  State Health Official 
CMS looks forward to working with states and territories as they implement the policy and systems 
changes to enroll eligible COFA migrants into the Medicaid program.  CMS staff is available to 
provide technical assistance regarding COFA migrants Medicaid and CHIP eligibility discussed in 
this letter.   
Questions regarding the Medicaid policies discussed in this letter may be directed to Sarah Lichtman 
Spector, Director, Division of Medicaid Eligibility Policy, at Sarah.Spector@cms.hhs.gov.  Questions 
regarding the CHIP policies may be directed to Meg Barry, Director, Division of State Coverage 
Programs, at Meg.Barry@cms.hhs.gov.  
Sincerely, 
Daniel Tsai 
Deputy Administrator and Director 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, 
unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding 
existing requirements under the law.  Page 10  State Health Official 
 
Appendix A 
Language for State Plan Amendment for a Territory Electing to Cover COFA Migrants 
The territory provides Medicaid eligibility to otherwise eligible individuals who lawfully reside in 
(name of territory) in accordance with the Compacts of Free Association (COFA) between the 
Government of the United States and the Governments of the Federated States of Micronesia, the 
Republic of the Marshall Islands, and the Republic of Palau. These individuals are not subject to the 
five-year waiting period described in 8 U.S.C.  1613(a). (8 U.S.C.  1612(b)(2)(G); 8 U.S.C.  
1613(b)(3); 8 U.S.C.  1641(b)(8)).  
   
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, 
unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding 
existing requirements under the law.  Page 11  State Health Official 
 
Appendix B 
Summary of Hub Changes to Verify COFA Migrant Immigration Status 
 
The Hub indictors provide the following results for COFA migrants and have been updated as 
follows: 
  Lawful Presence Verified =Y 
  Qualified Non-Citizen=Y27 
  Five-Year Bar Apply=N 
 
Description  Lawful  Qualified  Five-Year  Five-Year  U.S. Citizen 
Presence  Non- Bar Apply  Bar Met  Code 
Verified  Citizen 
Citizen of Micronesia,  Y  Y  N  X  X 
Marshall Islands, or Palau 
(COFAs) 
 
 
The following chart provides a summary of the Hub indicators and immigration codes that are being 
provided through the Hub/SAVE to assist states in verifying COFA migrant immigration status.  In 
addition to the Hub indicators, the Hub also provides the Class of Admission (COA) and other 
underlying immigration codes from SAVE that indicate COFA migrant immigration status.  
 
States that have the ability to receive and interpret SAVE immigration codes can use this information 
to verify COFA migrant immigration status.  For additional information, please refer to the Verify 
Lawful Presence (VLP) v37 Business Service Definition (BSD).. 
 
   
                                                 
27 Separate CHIP programs that rely on Hub indicators to determine eligibility for CHIP for non-citizens will need to 
develop eligibility system changes to make eligibility determinations for COFA migrants, as they are ineligible for 
separate CHIP coverage. 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, 
unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding 
existing requirements under the law.  Page 12  State Health Official 
 
Appendix B (continued) 
Summary of Hub Changes to Verify COFA Migrant Immigration Status 
  
VLP Step   COA  ESC  EAD  LPV   QNC   5-Year  Agency Action  
Codes   Code/  Category  Bar  
Major  code  
code  
H92 - Step 1   N/A  10   A08   Y   Y   N   Invoke CloseCase Web method 
to close the case.  
H92 - Step 1   MIS, FSM,  10   No EAD  Y  Y   N   Invoke CloseCase Web method 
or PAL   to close the case.  
H92 - Step 1   No COA  10   No EAD  P  P   P   Invoke InitiateAdditionalVerif 
or InitiateThirdVerif Web 
method.  
H92 - Step 1   MIS, FSM,  13   N/A   Y   Y   N   Invoke CloseCase Web method 
or PAL   to close the case.  
H92 - Step 1   MIS, FSM,  128   N/A   Y   Y   N   Invoke CloseCase Web method 
or PAL   to close the case.  
H92 - Step 1   PI   128, 10,  No EAD  Y   P   P   The Requester must ask for 
13   additional documentation from 
the individual. 
H100   MIS, FSM,  10a   N/A   Y   Y   N   Invoke CloseCase Web method 
Retrieve  or PAL   to close the case.  
Step 2  
H100   PI   10a   N/A   Y   P   P   The Requester must ask for 
Retrieve  additional documentation from 
Step 2   the individual. 
H101   MIS,  10a   N/A   Y   Y   N   Invoke CloseCase Web 
Retrieve  FSM, or  method to close the case.  
Step 3   PAL  
H101   PI   10a   N/A   Y   P   P   The Requester must ask for 
Retrieve  additional documentation 
Step 3   from the individual. 
 
 
The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, 
unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding 
existing requirements under the law.