DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland 21244-1850 
 
Center for Medicaid and State Operations 
                         
                   
 
December 28, 2009 
 
SHO #:09-016 
                  CHIPRA #: 11 
 
           RE: Citizenship Documentation Requirement 
 
Dear State Health Official: 
 
This letter is one of a series that provides guidance on the implementation of the Childrens 
Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Pub. L. 111-3.  Specifically, 
this letter addresses the provisions of section 211 regarding the citizenship documentation 
requirement for Medicaid and the Childrens Health Insurance Program (CHIP).  The Deficit 
Reduction Act of 2005 (DRA), Pub. L. 109-171, amended sections 1902 and 1903 of the Social 
Security Act (the Act), to require Medicaid applicants who declare to be a U.S. citizen or 
national to present satisfactory documentary evidence of citizenship prior to enrollment in 
Medicaid.  Section 211 of CHIPRA revises several of these requirements, and, effective 
January 1, 2010, applies these requirements to CHIP and permits States to verify citizenship for 
individuals newly enrolled using a data file match with the Social Security Administration 
(SSA).  This letter provides an overview and guidance on the changes made by section 211 of 
CHIPRA. 
 
Background 
 
Prior to enactment of the DRA, Medicaid applicants could attest under penalty of perjury that 
they were U.S. citizens or nationals.  States could require documentary evidence of citizenship or 
nationality but were not required to do so.  Effective July 1, 2006, the DRA created a new 
section 1903(x) of the Act which requires States to obtain satisfactory documentary evidence of 
citizenship or nationality when enrolling individuals in Medicaid or at the first point of eligibility 
redetermination.  Certain populations, including most individuals receiving Medicare, disability 
insurance benefits, supplemental security income benefits, children in foster care, and children 
receiving foster care or adoption assistance are exempt from these requirements.  Federal 
implementing regulations at 42 CFR 435.406 and 435.407 outline the groups of individuals that 
are subject to citizenship documentation requirements and describes the criteria for documents 
that can be provided to confirm citizenship.    
    Page 2   State Health Official 
CHIPRA Changes Related to Documentation of Citizenship in Medicaid and CHIP 
 
Section 211 of CHIPRA includes several provisions modifying the Medicaid requirement for 
documentation of citizenship, including a new option to assist States in meeting this requirement: 
 
  Eligible individuals who declare to be U.S. citizens or nationals must be provided a 
reasonable opportunity to present satisfactory documentation of citizenship or nationality  
and must be enrolled in coverage pending the reasonable opportunity to document that 
claim;   
  Tribal enrollment or membership documents issued from a federally recognized Tribe 
must be accepted as verification of citizenship; no additional identity documents are 
required.    
  Children who are initially eligible for Medicaid or CHIP as deemed newborns are 
considered to have provided satisfactory documentation of citizenship and may not be 
required to submit further documentation at subsequent eligibility determinations or re-
determinations;    
  A new State option, available beginning January 1, 2010, allows verification of a 
declaration of  citizenship for individuals newly enrolled in CHIP or Medicaid using a 
data match with SSA to confirm the consistency of a declaration of citizenship with SSA 
records, in lieu of the presentation of citizenship documentation; and  
  The citizenship verification requirements described above will apply to CHIP beginning 
January 1, 2010. 
 
Additional policy and regulatory guidance will be forthcoming on this issue and the Centers for 
Medicare & Medicaid Services (CMS) will continue to work with States to help them implement 
these provisions in a manner that is consistent with the statute.  
 
Reasonable Opportunity to Present Satisfactory Documentary Proof of Citizenship 
 
CHIPRA amends section 1903(x) of the Act requiring States to provide an individual who 
declares U.S. citizenship or nationality, under penalty of perjury, with at least the same 
reasonable opportunity to present evidence, as specified in sections 1137(d)(4)(A)(i) and (ii) of 
the Act, as individuals who are required to submit evidence indicating a satisfactory immigration 
status.  States have flexibility to define what constitutes a reasonable opportunity period, but may 
not apply a standard to citizens and nationals that is more restrictive than such standard applied 
to immigrants.   
 
Under this new provision, the State must allow an individual to declare citizenship and must not 
deny, delay, reduce, or terminate Medicaid or CHIP eligibility while the documentation is 
gathered during a reasonable opportunity period.  Once an individual has declared that he or she 
is a U.S. citizen or national and has provided all other information that the State needs to  
    Page 3   State Health Official 
determine eligibility, the State must make a decision on whether the applicant is eligible.  If the 
State determines that the individual is otherwise eligible, it must provide benefits while the 
individual secures the documents needed to satisfy the citizenship documentation requirement.  
The reasonable opportunity period does not affect the applicability of the timeliness standards at 
42 CFR 435.911.   
 
If an individual has not provided satisfactory documentation of citizenship by the end of the 
reasonable opportunity period, and any extension period, States may terminate that individuals 
eligibility for Medicaid or CHIP benefits in accordance with Medicaid rules at 42 CFR 435.919 
and 42 CFR 431 Subpart E (regarding timely notice and opportunity for a fair hearing).  Federal 
financial participation (FFP) will be provided for claims that occur during the reasonable 
opportunity period, even if eligibility is ultimately terminated due to lack of documentation. 
 
This provision took effect on July 1, 2006, as if included in the DRA.  (See Page 8 for further 
discussion.) 
 
Acceptance of Tribal Documents for Proof of Citizenship 
 
Section 211 of CHIPRA also clarified certain provisions of the DRA related to acceptance of 
documents issued by a federally recognized Indian Tribe for documentation of citizenship or 
nationality.  Section 1903(x)(3)(B) of the Act, as amended by CHIPRA, specifies that a 
document issued by a federally recognized Indian Tribe evidencing membership, enrollment in, 
or affiliation with such Tribe is satisfactory documentary evidence of an individuals U.S. 
citizenship or nationality.  The document must identify the Federally recognized Indian Tribe 
which issued it, identify the individual by name, and confirm the individuals membership,  
enrollment in, or affiliation with that Tribe.  Some examples include Tribal enrollment and 
membership cards, a certificate of degree of Indian blood issued by the Bureau of Indian Affairs, 
a Tribal census document, or a document issued by a Tribe indicating an individuals affiliation 
with the Tribe.  These documents are examples of documents that may be used, but do not 
constitute an all-inclusive list of such documents.  Tribal documents are now considered to be as 
reliable as a passport and are treated as Tier 1 documents under Federal regulations at 42 CFR 
435.407.  Additional identity documentation is not required to be presented.    
 
CMS will update current federal regulations authorizing the presentation of other forms of 
documentation, including Tribal documentation that may be used to satisfy the citizenship 
documentation requirements.  During the period that begins on July 1, 2006, and ends on the 
effective date of the final regulations (forthcoming), an individual who is a member of a 
federally recognized Indian Tribe who presents a Tribal document as described above is deemed 
to have presented satisfactory evidence of citizenship.    
    Page 4   State Health Official 
It is important for States to recognize that Tribes are individual independent governments that 
may not have uniform methods of documenting membership, enrollment, or affiliation with a 
particular Tribe.  CMS encourages States to contact Tribes located in their States for assistance 
in identifying documents used by those Tribes.  CMS will provide technical assistance to States 
and Tribes to assist in the implementation of this provision. 
 
With respect to federally-recognized Indian Tribes located within States having an international 
border and whose membership includes individuals who are not U.S. citizens, CHIPRA requires 
that the Secretary, after consultation with the Tribe, issue regulations regarding presentation of 
documentation sufficient to establish the citizenship of Tribal members who have declared they 
are citizens of the U.S.   
 
The CMS has consulted with the Tribes concerning the implementation of this provision.  
Specifically, the Tribal Affairs Group and the Center for Medicaid and State Operations within 
CMS jointly hosted an All Tribes call on June 19, 2009 to consult on this and other provisions in 
CHIPRA.  Two face-to-face consultation meetings were held in Denver on July 8, 2009, and July 
10, 2009, to solicit advice and input from federally-recognized Tribes, Indian health providers, 
and Urban Indian Organizations on these provisions.  In addition, CMS obtained the advice and 
input regarding implementation of section 211 from the CMS Tribal Technical Advisory Group 
at its July 30-31, 2009 meeting and no alternative types of Tribal documents were identified 
beyond the Tribal documents mentioned above.   
These provisions took effect on July 1, 2006, as if included in the DRA.  (See Page 8 for further 
discussion.) 
 
Children Born in the U.S. to Mothers Eligible for Medicaid or CHIP 
 
Section 1903(x) of the Act was also amended to provide that individuals who are initially 
eligible for Medicaid or CHIP as deemed newborns are considered to have provided 
satisfactory documentation of citizenship and identity (by virtue of being born in the United 
States) and will not be required to further document citizenship or nationality at any subsequent 
Medicaid or CHIP eligibility determination or redetermination.  Previously, under regulations 
promulgated pursuant to the DRA, documentation of citizenship was required at the first 
redetermination of Medicaid eligibility after the deemed newborn eligibility period ends, when 
the child turns 1 year old. CHIPRA repeals this regulatory requirement. CMS provided general 
guidance on the eligibility of deemed newborns in its August 31, 2009, letter to State Health 
Officials (SHO 09-009), available at 
http://www.cms.hhs.gov/smdl/downloads/SHO083109b.pdf.  
  
This provision took effect for Medicaid on July 1, 2006, as if included in the DRA.  (See page 8 
for further discussion.)   
    Page 5   State Health Official 
New State Option in Lieu of Requiring Documentary Evidence of Citizenship or 
Nationality 
 
Effective January 1, 2010, section 211 of CHIPRA amends section 1902(a)(46) of the Act by 
adding subparagraph (B) that provides a new optional State process at section 1902(ee) for 
documenting the citizenship or nationality for those Medicaid or CHIP applicants declaring to be 
U.S. citizens or nationals.  This process may be used in lieu of requiring the applicant to present 
satisfactory documentary evidence of citizenship or nationality as specified in 42 CFR 435.407.  
States that do not elect this option must continue to document citizenship and nationality in 
accordance with Federal regulations at 42 CFR 435.406 and 407 and policy requirements 
included elsewhere in this letter.   
 
In accordance with a new section 1902(ee) of the Act, a State may submit to SSA the applicants 
name, Social Security Number (SSN), and date of birth (DOB) for comparison with information 
that SSA has on record for the individual.  SSA will compare an individuals name, SSN, and 
citizenship declaration provided by the State with data in its Master File of SSN Holders 
(Numident).  States are expected to move forward with enrolling individuals during this 
verification period and eligibility may not be delayed, denied, or terminated pending the 
completion of the data matching process. 
 
SSA Operational Implementation of the New Option 
 
To support this exchange of information, SSA will use the existing electronic batch data 
exchange, known as the State Verification and Exchange System (SVES), currently in use for all 
States with SSA.  SVES operates via a network known as the File Transfer Management System.  
States currently send requests for SSN verification to SSA on a daily basis, and SSAs responses 
are sent to States the next day (referred to as an overnight batch).   
 
If a State elects the CHIPRA option for an SSA file match, the authority for entering into this 
data exchange will be documented by a revised Computer Matching and Privacy Protection Act 
(CMPPA) agreement and Information Exchange agreement that States will need to sign with 
SSA no later than December 31, 2009, if they wish to use this option beginning January 1, 2010.  
States that are currently operating separate CHIP eligibility programs will need to implement a 
process to connect to the State Medicaid agency to enable the processing of verification of 
citizenship for new applicants through SVES for CHIP.  As explained below, States may receive 
enhanced Federal matching payments for the design, development and installation of systems 
necessary to implement this electronic data matching option. 
 
In collaboration with CMS, SSA has been working closely with the States by incorporating  
CHIP into the CMPPA model agreements and has provided test cases for use by the States.  
CMS and SSA will continue to work closely with the States to ensure a smooth transition to this 
new system. 
    Page 6   State Health Official 
Operation of the Data Exchange 
 
For the citizenship verification inquiry, States will submit an SVES request that contains a 
special indicator of Medicaid/CHIP in the input field.  This request will provide the States with 
SSAs standard response as well as a specific response with respect to whether SSA can confirm 
the individuals attestation of U.S. citizenship or nationality.  SSA will match each individuals 
information provided by the State with SSAs records.  SSA will provide a response to every 
query submitted by the State.  Responses will indicate a confirmation of the data submitted by 
the State is consistent with SSA records, a response that indicates an inconsistency with SSA 
records, or a response that indicates that there is no match with SSA records.  The State will 
receive a reply for each record that SSA is unable to process due to missing or invalid data.   
 
A response from SSA that confirms that the data submitted by the State is consistent with SSA 
data, including citizenship or nationality, meets the citizenship verification requirements.  No 
further action is required for the State or individual and no additional documentation of either 
citizenship or identity is required. 
 
Resolution of Data Inconsistencies and Continued Enrollment 
 
An inconsistency between the data submitted by the States and SSAs data means that the States 
submitted information (individuals name, SSN, DOB, or citizenship declaration) is not a match 
with the information in SSAs Numident files.  In these instances, SSA does not provide the 
State a confirmation that citizenship is substantiated.  The State must correct its information and 
resubmit the request in order to obtain citizenship substantiation for the individual. 
 
If the State receives notice from SSA that the individuals name, SSN, DOB, or declaration of 
citizenship or nationality is inconsistent with information in SSAs records, or if no match is 
found by SSA, the State must first make a reasonable effort to identify and resolve the cause of 
this result (e.g., a typographical or other clerical error) that may have originated with the State 
and can be resolved by research of the States records.  If an error is identified, the State must 
correct its information and resubmit the request in order to confirm the citizenship verification 
for the individual.  If the inconsistency is not resolved by such efforts, the State shall notify the 
individual and provide the individual with 90 days from the date that the notice is received either 
to provide satisfactory documentation of citizenship or nationality to the State as described at 42 
CFR 435.406 and 435.407, or to resolve the inconsistency with SSAs information if the issue 
causing the discrepancy is related to the SSN, name, or date of birth.  The individual remains 
enrolled in Medicaid or CHIP during this effort.   
 
After 90 days, if the inconsistency has not been resolved or documentary evidence of citizenship 
or nationality has not been provided, the State must disenroll the individual with timely and 
adequate notice within 30 days.  The individual may appeal the disenrollment and request a fair 
hearing in accordance with standard notice and fair hearing procedures. 
  Page 7   State Health Official 
  
Reporting Requirements 
 
A State electing this SSN matching option must report to CMS the percentage of inconsistent 
submissions as compared to total submissions to SSA each month. For the purpose of this 
reporting, a submission is counted as inconsistent if the State could not resolve the inconsistency 
with SSAs records, the individual did not successfully resolve the inconsistency or provide 
satisfactory documentation of citizenship status after a reasonable opportunity, and CHIP or 
Medicaid paid for an item or service received by the individual.  CMS will issue additional 
guidance specifying the timeframe and format for this information.   
 
As required by the statute, if for any Federal fiscal year (FFY), the States average monthly rate 
of inconsistencies exceeds 3 percent, the State must develop and adopt a corrective action plan to 
review its procedures for verifying the identities of Medicaid and CHIP applicants, and must 
identify and implement changes in its procedures to improve the accuracy.  Also, the State must 
reimburse CMS a certain amount of Medicaid or CHIP payments for the FFY for individuals 
who provided inconsistent information, based on the number of individuals with inconsistent 
information in excess of 3 percent as a percentage of the total number of individuals with 
inconsistent information.  The Secretary of Health and Human Services (HHS) may waive, in 
certain limited cases, all or part of the payment if the State is unable to reach the allowable  
3 percent of inconsistencies despite a good faith effort.  CMS will issue separate guidance on the 
criteria for such waivers. 
 
Enhanced FFP for File Match System with SSA 
 
A State may claim FFP for 90 percent of the sums expended during a calendar quarter that are 
attributable to the design, development, or installation of a mechanized verification and 
information retrieval system that the Secretary of HHS determines is necessary to implement this 
option for a file match with SSA.  The 90 percent match will also be available for implementing 
a connection with a separate CHIP eligibility program to enable application of this process to 
CHIP.  The CHIP administrative expenditures cap does not apply to expenditures necessary for 
the State to implement this provision.  In addition, a State may claim FFP for 75 percent of the 
sums expended during a calendar quarter that are attributable to operation of these systems. 
 
Application of Citizenship Documentation Requirements to CHIP 
 
Effective January 1, 2010, section 2105(c) of the Act is amended to apply to separate CHIP 
programs the requirement to provide verification of citizenship or nationality as a condition of 
enrollment.  (The requirement currently applies to CHIP-funded Medicaid expansion programs, 
so this provision aligns the requirements for both programs.)   
 
    Page 8   State Health Official 
Separate CHIP programs are given the option to verify citizenship of new CHIP applicants using 
a file match with SSA in lieu of obtaining documentary evidence of citizenship or nationality.  
However, as stated above, SSA will not establish separate connections to separate CHIP 
programs.  Those programs must establish a connection through the States current Medicaid 
SVES data exchange.  
  
Restoration of Medicaid Eligibility 
 
As noted above, the effective date of the CHIPRA provisions related to reasonable opportunity, 
Tribal documentation, and citizenship of deemed newborns is July 1, 2006, the effective date of 
the DRA.  This retroactive effective date means that an individual previously determined 
ineligible for Medicaid, including under a section 1115 waiver program, during the period of 
July 1, 2006, through October 1, 2009, must be granted eligibility 1) if the individual was 
determined ineligible solely due to the requirements for documentation of citizenship or 
nationality in effect at the time the ineligibility determination was made; and 2) the individual 
would be eligible by applying the provisions of section 1903(x) that were amended by section 
211(b) of CHIPRA (i.e., Tribal documents, reasonable opportunity period, citizenship of deemed 
newborns).  In such case, the State must grant or restore the eligibility effective with the date the 
individual would have been eligible were these CHIPRA provisions in effect at the time of the 
determination of ineligibility.  
 
In addition, CHIPRA provides States with the option to deem individuals to be eligible 
retroactively to the date the individual would have been eligible if the States can identify 
individuals meeting criteria (1) and (2) discussed above.  Under this deeming option, the State 
would not need to perform a new eligibility determination, but rather, would be able to deem 
the individual as retroactively eligible and restore eligibility accordingly.  CMS will work with 
States interested in pursuing this option. 
 
Contact Information 
 
If you have questions regarding this guidance, please send an email to 
CMSOCHIPRAQuestions@cms.hhs.gov or contact Ms. Victoria Wachino, Director, Family and 
Childrens Health Programs Group, who may be reached at (410) 786-5647. 
 
          Sincerely, 
 
            /s/ 
 
          Cindy Mann 
          Director 
           
  Page 9   State Health Official 
  
cc: 
 
CMS Regional Administrators 
 
CMS Associate Regional Administrators 
Division of Medicaid and Childrens Health 
 
Ann C. Kohler 
NASMD Executive Director 
American Public Human Services Association 
 
Joy Wilson 
Director, Health Committee 
National Conference of State Legislatures 
 
Matt Salo 
Director of Health Legislation 
National Governors Association 
 
Debra Miller 
Director for Health Policy 
Council of State Governments 
 
Christine Evans, M.P.H. 
Director, Government Relations 
Association of State and Territorial Health Officials 
 
Alan R. Weil, J.D., M.P.P. 
Executive Director 
National Academy for State Health Policy