September 10, 1998  
Dear State Health Official:  
This letter is a follow-up to a letter issued by the Department of Health and 
Human Services on January 23, 1998 regarding opportunities for outreach to 
uninsured children. First, it highlights the flexibility States have to simplify the 
application and enrollment processes. Second, it provides clarification of two 
eligibility-related issues that have come to our attention as a result of the January 
letter: the provision of Social Security numbers (SSNs) for applicants and non-
applicant family members; and establishment of immigration status for non-
citizens.  
I. Application and Enrollment Simplification 
As we indicated in our letter dated January 23, 1998, a major key to successfully 
enrolling children in CHIP and Medicaid is a simple application and enrollment 
process. While it is important to maintain program integrity, a burdensome 
application and enrollment process can be a significant barrier to successful 
enrollment.  
Many States have already begun to simplify their application and enrollment 
processes. Listed below are actions that States already have taken, as well as 
some other recommendations that States could adopt to change their current 
processes and to reduce the stigma and complexity of seeking assistance:  
Shorten application forms and/or use mail-in applications;  
 
Create joint CHIP/Medicaid applications;  
 
Use joint Medicaid and CHIP applications;  
 
Eliminate assets test;  
 
Allow self-reporting of income by the family with follow-up verification by 
 
the State;  
Reduce verification/documentation requirements that go beyond Federal 
 
regulation;  
Allow redeterminations to be done by mail;  
 
Speed up processing;  
 
Develop a follow-up process for families not completing the application 
 
process;  
Establish an effective referral system between the States CHIP eligibility 
  agency, the Medicaid and maternal and child health programs, schools as well as 
other Federal and State agencies that serve low-income families;  
Offer phone interviews, or have transportation vouchers to assist 
 
individuals in getting to face-to-face interviews;  
Expand outstationing opportunities;  
 
Increase staff with multi-lingual ability;  
 
Extend office hours so that applicants do not have to take off work to apply 
 
for benefits;  
Take advantage of new options like presumptive eligibility and 12 month 
 
continuous eligibility; and  
Try to reduce stigma of seeking public assistance by using techniques such as a 
 
different name for program (such as Arkansas ARKids, Michigans MIChild, and 
Connecticuts HuskyCare).  
 
The Federal requirements for the application and enrollment process for 
Medicaid and for separate State CHIP programs provide a great deal of flexibility 
to States to design an application and enrollment process that is streamlined and 
simple, and avoids burdensome requirements for families that apply for benefits. 
For example, under Medicaid with the exception of obtaining documentation of 
immigration status for qualified alien applicants and the applicants Social 
Security numbers, States have flexibility to determine documentation 
requirements, including self-declaration of income and assets. In addition, States 
with separate CHIP programs can streamline and coordinate their application and 
enrollment processes for CHIP and Medicaid in a number of ways to make it 
easier for families to apply, including use of a joint application.  
The current application and enrollment requirements for Medicaid and separate 
State CHIP programs are listed in an attachment to this letter. They do not call for 
families to provide extensive amounts of documentation and information in order 
to file for benefits. For the most part, they deal in a very broad way with the basic 
elements of the application and enrollment process, and provide a great deal of 
flexibility to States to design a process that best suits their needs.  
Enrolling Americas uninsured children in Medicaid and CHIP is a national 
priority that requires an aggressive, sustained effort. There are many ways that 
States can, and are, modifying their processes to make them more user friendly. It 
is our hope that you will make, or continue to make, a firm commitment to 
simplify your application and enrollment processes in an effort to reduce barriers 
to enrolling uninsured children.  
II. Clarification of Eligibility Requirements   
Provision of Social Security Numbers (SSNs)  
Attached to the January 23, 1998 outreach letter was a model joint 
CHIP/Medicaid application States could use in order to simplify the eligibility 
process for this new program. One of the pieces of information requested on the 
model application was a SSN for all family members, including those who were 
not applying for benefits. We wish to clarify that, under Section 1137 of the Act, 
a SSN must be supplied only by applicants for and recipients of Medicaid 
benefits. In all other cases, including non-applicant parents of children applying 
for Medicaid and children applying for a separate State CHIP program (non-
Medicaid), States are prohibited from making the provision of a SSN by another 
family member a condition of the childs eligibility. This also applies to other 
members of the household whose income might be used in making the childs 
eligibility determination.  
A revised joint application form for CHIP/Medicaid children is enclosed. As you 
will see, the form now requires a SSN only for children applying for Medicaid 
benefits. For children applying for a separate State CHIP program (non-Medicaid) 
and members of the household not applying for benefits, the SSN is indicated as 
being optional.  
Some States use parents SSN as a means of verifying family income in the 
process of making an eligibility determination. While the statute does not require 
disclosure of the SSN for non-applicants, voluntary disclosure by the parent may 
facilitate the verification of income and contribute to a speedier and more accurate 
determination of the child's eligibility. States may advise parents and other 
household members of this as long as they do so in a manner that does not coerce 
provision of the SSN or deter application for benefits. Once more, we wish to 
clarify that States have no legal basis for denying an application based upon the 
failure to supply the SSN for verification purposes.  
 
III. Establishing Citizenship and Immigration Status of Non-Citizens 
Children who are citizens and who are applying for either Medicaid or a separate 
State CHIP program may establish their citizenship on the basis of self-
declaration; States are permitted to require further verification as a condition of 
eligibility. Children applying for either program who are qualified aliens must 
present documentation of their immigration status, which States must verify  using systems established for that purpose. The citizenship or immigration status 
of non-applicant parents (or other household members), however, is irrelevant to 
their childrens eligibility. States may not require that parents disclose this 
information.  
There are both statutory and programmatic bases for our policy. Under the statute 
(Section 1137 of the Act), there is no authority for requiring individuals other than 
those applying for benefits to provide their SSNs or to document their immigration 
status. Furthermore, the Privacy Act makes it unlawful for a State to deny benefits 
to an individual based upon that individuals failure to disclose the SSN, unless the 
disclosure is required by Federal law or was part of a Federal, State, or local 
system of records in operation before January 1, 1975. States may only seek the 
SSN of these individuals on a strictly voluntary basis. The CHIP law does not 
require applicants to provide SSNs and the Medicaid law only requires it for 
applicants and recipients of Medicaid benefits.  
From a programmatic point of view, asking non-applicants for their SSNs or 
evidence of immigration status may discourage immigrant parents, who may not 
wish to disclose information about themselves, from applying for benefits on 
behalf of their children who are U.S. citizens. When this occurs, the children are, 
in effect, denied access to medical care that they both need and are eligible for 
under the law.  
We encourage States to actively provide information to adults applying for 
benefits on behalf of their children to inform them that their childrens eligibility 
for Medicaid or CHIP is not contingent on disclosure of a parents SSN (or lack 
thereof), or on information about non-applicant parents immigration status.  
If you have questions or suggestions on any of these eligibility-related issues 
and the use or adaptation of the model form and guidance attached, please 
contact your HCFA regional office staff.  
Sincerely,  
Sally K. Richardson Director  
Attachments  
cc:  
All HCFA Regional Offices   All PHS Regional Offices  
HHS Regional Directors  
Lee Partridge American Public Human Services Association  
Nolan Jones National Governors Association  
Joy Wilson National Conference of State Legislators  
Cheryl Beversdorf Association of State and Territorial Health Officials  
Mary Beth Senkewicz National Association of Insurance Commissioners  
 
MODEL JOINT APPLICATION FOR CHIP/MEDICAID FOR CHILDREN  
[Revised 8/31/98]  
Purpose: The attached model joint application can be used for both the Childrens 
Health Insurance Program (CHIP) and childrens Medicaid eligibility (under the 
childrens poverty level related groups). States could allow individuals to use this 
form to apply for both programs and the information on this form would be 
sufficient for determining which program a child is eligible for. It includes only 
the information that is required in all circumstances, and it is provided as a base 
form that a State can adapt to meet its own needs. As presented, the form is 
suitable for completion by an intake worker. Modifications would be required to 
make the form suitable for direct completion by the applicant.  
 
Screening:  
This application will meet the statutory requirement in Title XXI that States 
identify children who are eligible for Medicaid.  
NOTE: Non-State employees cannot determine Medicaid eligibility. Therefore, in 
a State that has contracted out the process of CHIP eligibility determination (i.e., 
determinations are performed by non-State employees), this model application 
would have to be modified for use as a pure screening form (or a combination of  an application for CHIP and a screening form) by removing all references to it as 
a Medicaid application. The statement about the use of the Social Security 
Number  still would be required. The inclusion of the section on rights and 
responsibilities  (but omitting any reference to Medicaid), however, would be at 
State option.  
If the form were so modified, in order to permit the information on the form to be 
submitted for use in making a Medicaid determination, the eligibility workers could 
provide a separate page to be completed by those whom the screen indicates are 
Medicaid-eligible. On that page, the individual should consent to submission of the 
information as part of a Medicaid application, and accept the rights and responsibilities 
outlined in this model (including a statement under penalty of perjury that the 
information provided on the "attached screening form" or "attached CHIP application" is 
correct). Once this page is completed, the form could be forwarded to the State for a 
Medicaid eligibility determination.  
 
Mandatory Information About Medicaid:  
If a State uses a joint CHIP/Medicaid application and denies the Medicaid 
application, then the State must thoroughly inform the individual about the 
availability of Medicaid and his or her right to apply for Medicaid on a basis 
other than as a poverty-level child. This includes an explanation of the Medicaid 
program and the various eligibility groups, the advantages of Medicaid over 
CHIP and information about how and where to apply for Medicaid.  
 
Federal Verification Requirements:  
Under Federal law, there are no verification requirements pertaining to eligibility 
for the children under Medicaid other than those related to alien status of non-
citizens, the post-eligibility requirements of 1137 pertaining to use of the 
individuals Social Security Number and an income and eligibility verification 
system. Eligibility of a citizen child may be established on the basis of self-
declaration under penalty of perjury. States are permitted, however, to require 
further verification as a condition of eligibility.  
Section 1137's requirement for furnishing a Social Security number applies only to 
the applicants for and recipients of Medicaid. It does not apply to the parents of 
Medicaid applicants, nor does it apply to a State-run Childrens Health Insurance  Program that is separate from the States Medicaid program. The Privacy Act,  7 
of Public Law No. 93-579, 88 Stat. 1896, makes it unlawful for a State to deny 
benefits to an individual based upon that individuals failure to disclose the Social 
Security number unless the disclosure is required by federal law or was part of a 
federal, State, or local system of records in operation before January 1, 1975. 
Since the new CHIP program does not require that Social Security Numbers be 
supplied and the Medicaid program requires it only for applicants and recipients, 
States may seek these account numbers from applicants for a non-Medicaid CHIP 
program only on a strictly voluntary basis.  
 
Additional Simplification of Medicaid Eligibility Determination:  
If the total gross income of the family is at or below the applicable Medicaid 
income standard, the questions in the shaded areas need not be answered. The 
individual is obviously income eligible for Medicaid without further information.  
 
Explanation of Certain Fields:  
There are some questions on the application that may not elicit all 
the information needed to make a determination. Under certain 
circumstances, additional information will be required. For example:  
If the answer to the question about citizenship [18] is no, actual status will 
 
need to be determined, official documents submitted, etc.  
If the child has insurance [22] and is Medicaid-eligible, information about 
 
the insurance company and policy number will be needed; and  
If the child had medical bills in the last 3 months [32] and is Medicaid-
 
eligible, eligibility information for the last three months will be needed to establish 
retroactive eligibility, in addition to information about the bills.  
 
In addition, the question concerning employment by a public agency in the State 
is only needed for CHIP eligibility and is not needed for Medicaid. This field 
does not ask directly about the availability and nature of health insurance, on the 
assumption that the eligibility worker would have access to a list of public 
agencies that offer State health insurance of the type that would preclude CHIP 
eligibility. If this is not the case in your State, this field would need to be 
expanded.  
  Examples of State Modifications:  
A State may wish to include voter registration; or  
 
A State may want to use this as an application for Medicaid for the adults, 
 
which would require additional information about the adults and stock affidavits 
concerning assignment of rights and pursuit of support.  
A State will need to add a question concerning each individuals resources 
 
(assets) if:  
-the State applies a resource test for the poverty level children; or  
-the State has not chosen to cover children born before 10/1/83 under the 
poverty level group AND the State applies a resource test for the optional 
group of categorically needy children ("Ribicoff children").  
 
-- SAMPLE --  
CHILDRENS HEALTH INSURANCE PROGRAM / MEDICAID  
JOINT APPLICATION FORM [Revised 8/31/98]  
I. Person Applying for the Child or                 
Children  
Name  
         
[ 1] FIRST MIDDLE LAST  
 
   
Home Phone [2]   Work             
Phone [3] 
   
   
 
 
Home Address   Apt. # [5]  City [6]   State [7]   Zip [8]   County 
[9]  
[4]Street  
   
Mailing Address   Apt. # [11]  City [12]   State [13]  Zip [14]   County 
[15]  
( if different from above)  
[10] Street      
   
 
II. Family Members Living in the Home      
(Attach extra sheet if needed)  
Children (under  Date  Citizen   Social  Mothers  Fathers  Covered 
19) living in the  of  Security  Name  Name  by Health 
(Yes or No 
home   Birth  Number  [20]   [21]   Insurance 
-- If no, see 
[17]   [required  other than 
NAMES [16]   also 
for  Medicaid 
attachment) 
applicants  [Yes or 
[18]  
--  No] If 
otherwise  yes, what 
optional]  insurance? 
[19]   [22]  
                           
                       
                           
                           
                           
                           
Adults living in the         
home  
Social Security  If employed by a public agency in the State, what 
NAMES [23]   Number [  agency? [25]  
optional][24]  
           
                   
           
 
   
III. Income and Child Care Payments  
List all the Income Received by Family Members Listed Above  
(Attach Extra Sheet if Needed)  
Name of person(s)  Who provides the money?  How Often?   What 
working   [27]   amount? [29]  
[28]  
or receiving money* [26]   Employer, program or  Weekly, twice a  Before taxes or 
person   month, monthly   any deductions  
1.              
       
               
2.          
               
3.          
   
*Be sure to include all sources of gross income (before taxes) such as wages, dividends & 
interest, TANF, SSI annuities, pension, disability, child support, alimony, cash gifts, & other 
unearned income.  
List the payments made for child care  
(or care for an adult who cannot care for himself) so that someone in your household can 
work. [30]   Name of person(s) who  Name of  Under  How Often?   What 
works   Person Care  Age 2?   amount?  
For  
                   
    Yes      
  No    
 
   
IV. Medicaid Questions  
Is any child   Do any of the children have unpaid 
medical bills from the last 3 months?  
: [31] Pregnant: Yes  
  No   In an Institution: Yes   No     [32] Yes   No    
 
 
Social Security Number (SSN)  
If you are applying for Medicaid for a child, you are not required to provide your 
own Social Security Number (SSN), but we must have the childs SSN in order for 
the child to receive Medicaid. If you are applying for CHIP [State-specific 
program name] for a child, you are not required to provide either your own or the 
childs SSN. If you are applying for Medicaid for yourself, you must provide your 
SSN. This policy is dictated by section 1137(a (1) of the Social Security Act and 
the Medicaid regulations at 42 CFR 435.910. The Medicaid agency will use the 
SSN to verify your income, eligibility, and the amount of medical assistance 
payments we will make on your behalf. It is possible that the Medicaid agency 
will also use the SSN to determine another persons right to Medicaid or to 
comply with Federal law requiring that we release information from Medicaid 
records. The information may be matched with the records in other agencies, such 
as the Social Security Administration or the Internal Revenue Service. These 
matches may be done by computer or on an individual basis.   Rights and Responsibilities  
I agree to the release of personal and financial information from this application 
form and supporting documents to the agencies that run these programs so that 
they can evaluate it and verify eligibility. I understand that the agencies that run 
the programs will determine confidentiality of this information according to the 
federal laws, 42CFR 431.300-431.307.1, and any applicable federal and state laws 
and regulations.  
Officials from the programs that I, or members of my household, have applied for 
may verify all information on this form.  
I understand that I must immediately tell the Medicaid agency about any changes 
in information on this form.  
I understand that I may be asked to provide additional information.  
I understand my eligibility will not be affected by my race, color, national origin, 
age, disability, or sex, except where this is required by law.  
Signature  
Date  
 
Date Received by Agency  
 
I understand that this application is an application for one kind of childrens health 
benefits under Medicaid and is not a full Medicaid application. I understand that if 
I am not found eligible for this kind of childrens health benefits under Medicaid, I 
may be eligible for Medicaid benefits on some other basis and have a right to 
complete a full Medicaid application.  
I have the right to appeal any decisions made by a local Medicaid program. 
Information on the appeals process can be obtained from the local Medicaid 
agency.   I understand that anyone who knowingly lies or misrepresents the truth or arranges 
for someone to knowingly lie or misrepresent the truth is committing a crime 
which can be punished under federal law, state law, or both. I understand that I 
may also be liable for repaying in cash the value of the benefits received and my 
be subject to civil penalties.  
I certify under penalty of perjury that everything on this application form is the 
truth as best I know.  
Application and Enrollment Requirements for Medicaid and Separate State 
CHIP  
 
1. Requirements for Separate State (non-Medicaid) CHIP 
If a State chooses to develop a separate State (non-Medicaid) CHIP program, the 
only Federal requirements for the application and enrollment process for CHIP 
are:  
A screening and enrollment process designed by the State to ensure that 
 
Medicaid eligible children are identified and enrolled in Medicaid; and  
For qualified aliens, verification of applicants immigration status with 
 
INS.  
 
 
2. Requirements for Medicaid 
The Federal requirements for the application and enrollment process for 
Medicaid (includingCHIP-related Medicaid programs) are explained in 42 
CFR 435.900ff. Specifically, States must:   Give individuals the opportunity to apply for Medicaid without delay. Pregnant 
 
women and infants must have the opportunity to apply for Medicaid at required 
outstation locations other than welfare offices.  
Require a written application on a form prescribed by the State Medicaid 
 
agency and signed under a penalty of perjury. The application must be filed by the 
applicant, an authorized representative, or if the applicant is incompetent or 
incapacitated, someone acting responsibly for the applicant.  
Provide written (or oral, if appropriate) information to all applicants on 
 
Medicaid eligibility requirements, available services, and the rights and 
responsibilities of applicants and recipients. The State also must have pamphlets or 
bulletins that explain the eligibility rules and appeal rights in simple, 
understandable terms.  
Obtain the Social Security number (SSN) of the applicant. (Note that the 
 
SSN cannot be required of other family members who are not applying for 
Medicaid).  
If the applicant is a qualified alien, obtain documentation of satisfactory 
 
immigration status and verify immigration status with INS. (Note that this 
requirement does not apply to parents if the parents are not applying for 
Medicaid).  
Take action on applications within a time standard set by the State (not to 
 
exceed 45 days for individuals who apply on a basis other than disability) and 
inform the applicant about when a decision can be expected.  
Record in each applicants case record facts to support its eligibility 
 
decision.  
Send a written decision notice to every applicant. If the application is 
 
denied, the notice must include the reasons for the denial, the specific regulations 
supporting the action and an explanation of the applicants right to a hearing.  
 
It also is important to note that the States application and enrollment process 
must be consistent with our data collection requirements.  
Federal law requires no verification of information pertaining to eligibility for 
children under Medicaid other than the requirement for verification of 
immigration status of qualified aliens, and the post-eligibility requirement in 
Section 1137 for an income and eligibility verification system (IEVS). Under 
IEVS, the State must request information from other Federal and State agencies 
to verify the applicants income and resources. The applicant must be informed 
in writing, at the time of application, that the agency will be requesting this 
information.