Department of Health and Human Services


OFFICE OF 

INSPECTOR GENERAL 

SELF-DECLARATION OF U.S. 


CITIZENSHIP FOR MEDICAID


Daniel R. Levinson


Inspector General 


July 2005


OEI-02-03-00190

Office of Inspector General 
 http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, 

as amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by 

conducting audits with its own audit resources or by overseeing audit work done by others. 

Audits examine the performance of HHS programs and/or its grantees and contractors 

in carrying out their respective responsibilities and are intended to provide independent 

assessments of HHS programs and operations in order to reduce waste, abuse, and 

mismanagement and to promote economy and efficiency throughout the department. 

Office of Evaluation and Inspections 

The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management 

and program evaluations (called inspections) that focus on issues of concern to the 

department, the Congress, and the public. The findings and recommendations contained 

in the inspections reports generate rapid, accurate, and up-to-date information on the 

efficiency, vulnerability, and effectiveness of departmental programs. The OEI also 

oversees State Medicaid fraud control units, which investigate and prosecute fraud and 

patient abuse in the Medicaid program. 

Office of Investigations 

The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative 

investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries 

and of unjust enrichment by providers. The investigative efforts of OI lead to criminal 

convictions, administrative sanctions, or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

the OIG, rendering advice and opinions on HHS programs and operations and providing 

all legal support in OIG's internal operations. The OCIG imposes program exclusions 

and civil monetary penalties on health care providers and litigates those actions within 

the department. The OCIG also represents OIG in the global settlement of cases arising 

under the Civil False Claims Act, develops and monitors corporate integrity agreements, 

develops compliance program guidances, renders advisory opinions on OIG sanctions to 

the health care community, and issues fraud alerts and other industry guidance. 
ΔEXE CUTIVE S U MMAR Y

 EXECUTIVE SUMMAR Y 

OBJECTIVES 

Our objectives were to determine the extent to which States allow 

self-declaration of U.S. citizenship for Medicaid and related programs 

and to identify potential vulnerabilities, if any, associated with 

quality control activities and evidence used to document citizenship. 

BACKGROUND 

The Personal Responsibility and Work Opportunity Reconciliation Act 

of 1996 restricts eligibility for Medicaid to U.S. citizens, nationals of 

the United States, or qualified aliens. Since 1986, verification of U.S. 

citizenship for purposes of Medicaid eligibility has been governed by 

section 1137(d) of the Social Security Act (the Act). The Act requires 

“a declaration in writing, under penalty of perjury . . . stating whether 

the individual is a citizen or national of the United States.” Pursuant 

to the Act, the Centers for Medicare & Medicaid Services (CMS) 

allows, but does not require, States to accept self-declaration of 

citizenship without requiring submission of additional documentary 

evidence. In September 2002, CMS planned to issue a final rule that 

would permit States to continue using self-declarations of citizenship 

for Medicaid eligibility.1 At that time, OIG agreed to conduct an 

inspection on the extent to which States allow self-declaration. 

Subsequently, CMS withdrew the proposed rule. However, OIG 

completed the inspection because of its potential value in the 

administration of the program. 

In recent years, CMS has encouraged self-declaration in an effort to 

simplify and accelerate the Medicaid application process.2 While the 

policy to allow applicants to self-declare citizenship can result in rapid 

enrollment, it can also result in inaccurate eligibility determinations 

for applicants who provide false citizenship statements. As such, 

there are inherent challenges in trying to provide Medicaid benefits 

expeditiously while still ensuring the accuracy of eligibility 

determinations. In a 2001 pamphlet, CMS provided information on 

how to maintain program integrity while attempting to simplify the 

1 Centers for Medicare & Medicaid Services, “Medicaid Program: Self-Declaration of 

Citizenship,” CMS-2085-P, Sept. 12, 2002. 

2 Centers for Medicare & Medicaid Services, “Continuing the Progress: Enrolling and 

Retaining Low-Income Families and Children in Health Care Coverage,” Pub. No. 11000, 

Aug. 2001. 

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EXE CUTIVE S CUTIVE S U MMAR Y

application process. These strategies include verifying the accuracy of 

citizenship statements against other nonapplicant sources, such as 

State vital statistics databases, and/or conducting posteligibilityfocused reviews.3 

For this inspection, we gathered information from State Medicaid 

directors and their staff responsible for quality control activities. 

Additionally, we surveyed State Temporary Assistance for Needy 

Families (TANF) directors, State foster care directors, and Social 

Security Administration (SSA) officials. 

FINDINGS 

Forty-seven States allow self-declaration of U.S. citizenship for 

Medicaid; nearly all of these require evidence if statements seem 

questionable. Pursuant to Federal policy, States may accept a 

signed declaration as proof of U.S. citizenship from applicants seeking 

Medicaid benefits. Currently, 40 Medicaid directors report that their 

State allows self-declaration of citizenship. An additional seven 

report that self-declaration is sometimes allowed. The four remaining 

directors report that self-declaration is not permitted in their State. 

These States are Montana, New Hampshire, New York, and Texas. 

Forty-four of the forty-seven States that allow or sometimes allow 

self-declaration have “prudent person policies” which require evidence 

of citizenship if statements seem questionable to eligibility staff. 

Thirty-two of these have written prudent person policies, and the 

remaining 12 have unwritten, informal policies requiring 

documentation for questionable statements. 

Twenty-seven States do not verify the accuracy of any U.S. 

citizenship statements as part of their posteligibility quality 

control activities. In fiscal year 2003, 27 of the 47 States that allow 

self-declaration did not conduct quality control activities that included 

verification of statements of U.S. citizenship. Of the 20 States that 

did review statements, 9 did so for a nonrepresentative sample of the 

entire Medicaid population. Consequently, some groups that could 

pose vulnerability to Medicaid integrity were not included in the 

review sample. 

3 Centers for Medicare & Medicaid Services, “Continuing the Progress: Enrolling and 

Retaining Low-Income Families and Children in Health Care Coverage,” Pub. No. 11000, 

Aug. 2001. 

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EXE CUTIVE S U MMAR Y

Some States use types of evidence that are not accepted by CMS 

or SSA to document citizenship for Medicaid. As reported earlier, 

seven States sometimes allow and four States do not allow Medicaid 

applicants to self-declare citizenship. Of these 11 States, 4 use types 

of evidence to document citizenship that are not accepted by CMS or 

SSA. Furthermore, 13 of the 20 States that report conducting quality 

control to verify statements of U.S. citizenship use types of evidence 

that are not accepted by CMS or SSA, such as school records, family 

Bibles, voter registration records, and marriage licenses. 

Medicaid-related programs are more likely to verify citizenship; 

their verifications may be a useful resource for Medicaid. SSA 

states that all applicants must provide documentary evidence of U.S. 

citizenship in order to receive a Social Security number or qualify for 

Supplemental Security Income (SSI) benefits. Forty-two of fifty-one 

foster care directors report that staff document U.S. citizenship when 

determining eligibility for Title IV-E foster care maintenance 

payments. Twenty-seven of fifty-one TANF directors report 

documenting or sometimes documenting citizenship for purposes of 

eligibility. 

In the majority of instances, we found that these Medicaid-related 

programs draw on evidence accepted by CMS or SSA to document 

statements of U.S. citizenship. These citizenship verifications may be 

a useful resource for Medicaid. 

RECOMMENDATIONS 

We recognize that there are challenges in providing Medicaid benefits 

expeditiously while ensuring the accuracy of eligibility determinations. 

By their nature, self-declaration policies have inherent vulnerabilities 

in that they can allow applicants to provide false statements of 

citizenship. As such, it is vital to have protections in place to prevent 

such practices. 

Based on the descriptive information we collected from States, we 

conclude that existing safeguards at the point of entry into Medicaid 

and during posteligibility quality control could allow false statements of 

citizenship to go undetected. Below are three recommendations for 

improving safeguards: 

• CMS should strengthen posteligibility quality controls in States that 

allow self-declaration. 

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EXE CUTIVE S U MMAR Y 

• CMS should issue a complete list of evidence that States may 

reference when determining eligibility. 

• CMS should explore allowing State Medicaid staff to use citizenship 

verifications from other Medicaid-related programs as an additional 

resource. 

AGENCY COMMENTS 

CMS concurred with our recommendations. The agency further 

commented that it has already taken steps to improve safeguards to 

prevent applicants from providing false statements of citizenship. The 

full text of CMS’s comments is included in Appendix D. 

We note several issues with CMS’s current efforts. Specifically, CMS 

explained that, pursuant to Federal regulations, States must verify 

statements of citizenship for sampled active cases as part of their 

posteligibility quality control procedures. We reiterate that this 

regulation applies only to States that operate traditional quality control. 

States that operate under a pilot or a section 1115 waiver with a quality 

control component are not required to verify all elements of eligibility, 

including statements of citizenship, as part of their posteligibility case 

file review. 

CMS also commented that States choosing to accept self-declaration of 

citizenship need to have systems in place for some type of posteligiblity 

check to ensure that the self-declaration procedure is reliable. CMS 

stated that it is taking steps to do this by requiring a review of the 

accuracy of eligibility determinations as part of the Payment Error Rate 

Measurement (PERM) project. Currently, the Office of Management 

and Budget is working with CMS to define the scope of the PERM 

project. As of June, no decision has been made regarding the inclusion 

of errors related to Medicaid eligibility determinations. 

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Δ T ABLE OF CONTENTS 

EXECUTI VE SUMMARY ......................................... i 

INTRODUCTI ON ................................................ 1 

FINDI NGS ... .................................................... 9 

States allowing self-declaration of citizenship .................. 9 

Posteligibility quality control activities........................ 11 

Forms of evidence used to document citizenship................ 14 

Practices in Medicaid-related programs ....................... 15 

RECOM M E NDATI O NS ......................................... 18 

APPENDI XES .................................................. 20 

A: Evidence Accepted to Document Statements of Citizenship .. 20 

B: Medicaid Eligibility Quality Controls in States Allowing 

 Self-Declaration.......................................... 22 

C: Related Program Policies on Self-Declaration............... 24 

D: Agency Comments ....................................... 26 

ACKN O W LEDGMENTS ......................................... 29 
Δ INTRODU C TION 

OBJECTIVES 

Our objectives were to determine the extent to which States allow 

self-declaration of U.S. citizenship for Medicaid and related programs 

and to identify potential vulnerabilities, if any, associated with 

quality control activities and evidence used to document citizenship. 

BACKGROUND 

Title XIX of the Social Security Act (the Act) establishes Medicaid as a 

jointly funded, Federal-State health insurance program. To qualify 

for the full range of Medicaid benefits provided under a State plan, an 

applicant must be either a citizen or a national of the United States or 

a qualified alien.4 Since 1986, verification of U.S. citizenship for 

purposes of Medicaid eligibility has been governed by section 1137(d) 

of the Act, which requires “a declaration in writing, under penalty of 

perjury . . . stating whether the individual is a citizen or national of 

the United States.”5 Pursuant to the Act, the Centers for Medicare & 

Medicaid Services (CMS) allows, but does not require, States to accept 

self-declaration of citizenship without requiring submission of 

additional documentary evidence. In September 2002, CMS planned 

to issue a final rule that would permit States to continue using selfdeclarations of citizenship for Medicaid eligibility.

6 At that time, OIG 

agreed to conduct an inspection on the extent to which States allow 

self-declaration. Subsequently, CMS withdrew the proposed rule. 

However, OIG completed its inspection because of its potential value 

in the administration of the program. 

In recent years, CMS has encouraged self-declaration in an effort to 

simplify and accelerate the Medicaid application process.7 While the 

policy to allow applicants to self-declare citizenship can result in rapid 

4 The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 

 (PL 104-193). 

5 Social Security Act § 1137 (d)(1)(A). 

6 Centers for Medicare & Medicaid Services, “Medicaid Program: Self-Declaration of 

Citizenship,” CMS-2085-P, Sept. 12, 2002. 

7 Centers for Medicare & Medicaid Services, “Continuing the Progress: Enrolling and 

Retaining Low-Income Families and Children in Health Care Coverage,” Pub. No. 11000, 

Aug. 2001. 

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INTROD UCT ION 

enrollment, it can also result in inaccurate eligibility determinations 

for applicants who provide false citizenship statements. As such, 

there are inherent challenges in trying to provide Medicaid benefits 

expeditiously while still ensuring the accuracy of eligibility 

determinations. In a 2001 pamphlet, CMS provided information on 

how to maintain program integrity while attempting to simplify the 

application process. These strategies include verifying the accuracy of 

citizenship statements against other nonapplicant sources, such as 

State vital statistics databases, and/or conducting posteligibilityfocused reviews.8 

Personal Responsibility and Work Opportunity Reconciliation Act of 1996 

The Personal Responsibility and Work Opportunity Reconciliation Act 

of 1996 (PRWORA) restricts eligibility for means-tested, federally 

funded public benefit programs to U.S. citizens or qualified aliens. 

This same legislation directed the Attorney General to establish 

verification guidance and procedures that States must follow in 

verifying the citizenship or immigration status of individuals applying 

for federally funded public benefit programs. The U.S. Department of 

Justice (DOJ) issued interim guidance in 1997 (62 FR 61344) and 

proposed regulations (63 FR 41662) in 1998. Final rules have not yet 

been issued. 

The proposed DOJ regulations would require that both citizens and 

qualified aliens who are applying for Medicaid provide documentary 

evidence to verify their status. However, the proposed regulations 

would permit Federal benefit-granting agencies to establish 

alternative procedures for verifying citizenship. The agencies would 

be required (1) to publish regulations that provide for fair and 

nondiscriminatory procedures for verifying the citizenship of 

applicants for the benefit in question and (2) to obtain approval from 

the Attorney General for the alternative procedures. 

CMS set forth its policy concerning self-declaration in a letter dated 

September 10, 1998, to State Medicaid directors. The letter explained 

that States may accept self-declaration of citizenship without 

8 Centers for Medicare & Medicaid Services, “Continuing the Progress: Enrolling and 

Retaining Low-Income Families and Children in Health Care Coverage,” Pub. No. 11000, 

Aug. 2001. 

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INTROD UCT ION

requiring submission of additional documentary evidence. On 

January 11, 2001, CMS published final regulations (42 CFR 

457.320(c)) that permit States to accept self-declaration of citizenship 

for applicants applying for coverage under the State Children’s 

Health Insurance Program, a State-run insurance program intended 

to provide health care coverage to certain low-income families.9 

Evidence of Citizenship 

The Department of Homeland Security (DHS), Bureau of Citizenship 

and Immigration Services is responsible for determining U.S. 

citizenship for persons in the United States.10 Currently, DHS does 

not have a comprehensive list of acceptable evidence that may be used 

to document citizenship. 

The CMS State Medicaid Manual contains two lists of evidence that 

may be accepted as proof of citizenship. These lists differ somewhat 

and neither is comprehensive. Examples of acceptable evidence listed 

in the manual include: 

• Birth certificate, 

• U.S. passport, 

• Report of Birth Abroad of a Citizen of the United States, and 

• Naturalization Certificate (INS Forms N-550 or N-570).11 

In its operations manual, the Social Security Administration (SSA) 

provides additional sources of evidence that may be used to document 

U.S. citizenship for purposes of establishing eligibility for SSAsponsored benefits. 

See Appendix A for a listing of the evidence accepted by CMS or SSA 

to document U.S. citizenship. 

Medicaid Eligibility Quality Control 

Federal regulations require State Medicaid agencies to conduct 

posteligibility quality control activities to “eliminate or substantially 

reduce dollar losses resulting from eligibility errors.”12 From 1978 to 

9 66 FR 2490. 

10 Homeland Security Act of 2002 § 402(3). 

11 State Medicaid Manual, § 3212.3, “Methods of Documenting United States Citizenship.” 

12 42 CFR § 431.800. 

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INTROD UCT ION 

1993, States were required to conduct “traditional” eligibility case 

reviews of the Medicaid-eligible population. As part of these 

traditional reviews, all States were required to review and verify 

elements such as citizenship and alienage, wage information, age, and 

residency. To verify information on citizenship, quality control staff 

were required to obtain documentation supporting the content of the 

declaration of citizenship.13 

In 1994, CMS offered States three options for conducting Medicaid 

Eligibility Quality Control (MEQC). States could continue using 

traditional quality control, participate in a demonstration pilot 

program, or conduct quality control as part of a section 1115 waiver.14 

In fiscal year 2003, 39 States operated under a section 1115 waiver or 

an MEQC pilot.15 

MEQC pilots. MEQC pilots allow States to develop innovative and 

targeted approaches for conducting quality control. Under pilots, 

States may tailor their programs to look at error-prone areas, highdollar areas, or special populations. While operating under pilots, 

States are not required to conduct reviews of self-declaration of 

citizenship statements. 

Section 1115 waivers. Under section 1115 waivers, States may allow 

certain kinds of deviations from their State Medicaid plans, including 

the expansion of eligibility for those who would otherwise not be 

eligible for the Medicaid program. Unless outlined in their contract 

with CMS, States operating under section 1115 waivers with quality 

control components are not required to conduct reviews of citizenship 

statements. 

Related Benefit Programs 

Other programs in which Medicaid recipients could potentially 

participate include Supplemental Security Income (SSI), Title IV-E 

foster care, and Temporary Assistance for Needy Families (TANF). 

We examined eligibility requirements and State policies and practices 

13 State Medicaid Manual, Chapter III, 7269.130. 

14 CMS Medicaid Quality Control Program, http://www.cms.hhs.gov/medicaid /meqc/mqcguid.asp, 

accessed Jan. 22, 2004. 

15 Centers for Medicare & Medicaid Services, “National Overview of Medicaid Eligibility 

Quality Control for 2003,” May 9, 2003. 

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INTROD UCT ION

regarding self-declaration of U.S. citizenship for these related 

programs in an effort to identify a potential resource for Medicaid 

staff. Throughout this report, we refer to the SSI, foster care, and 

TANF programs as “Medicaid-related programs.” 

SSI. In general, States are required to provide Medicaid coverage to 

recipients of SSI. SSA requires that 

all Supplemental Security Income (SSI) applicants alleging U.S. 

citizenship must submit evidence. However, if an individual 

actually provided proof of his/her citizenship status in a prior 

claim for benefits from SSA, he/she will not have to resubmit that 

evidence.

16 

Title IV-E foster care. Section 471(21) of the Act requires States to 

provide Medicaid or equivalent health insurance coverage to children 

eligible to receive Title IV-E foster care program maintenance funds. 

For all children receiving Federal foster care maintenance payments, 

States are required to verify citizenship or immigration status.17 

TANF. Similar to Federal requirements related to documenting U.S. 

citizenship for Medicaid, current Federal law does not impose any 

specific documentation requirements, other than a signed declaration 

of U.S. citizenship, for TANF applicants claiming to be U.S. citizens.18 

SCOPE 

This inspection describes State practices to determine and document 

U.S. citizenship for Medicaid and related program eligibility, as well 

as State quality control activities. It does not identify the extent to 

which current Medicaid beneficiaries are ineligible on the basis of 

their citizenship. In addition, this inspection does not examine the 

extent to which eligible individuals fail to apply for Medicaid in States 

that require proof of U.S. citizenship as a condition of eligibility. 

16 The SSA Program Operations Manual System, “Special Procedure for Establishing U.S. 

Citizenship for SSI Benefits,” GN 00303.350, May 1995. 

17 “ACF Child Welfare Policy Manual – WC Policy Database – Policy Questions & 

Answers,” Question 9, June 4, 2003. 

18 Social Security Act § 1137 (d)(1)(A). 

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INTROD UCT ION

METHODOLOGY 

To identify States that allow self-declaration of U.S. citizenship for 

Medicaid and related programs, we gathered information from State 

Medicaid Directors and their staff responsible for quality control, as 

well as SSA officials, State foster care directors, and State TANF 

directors. 

The data presented in this report were collected from State 

representatives in the 50 States and the District of Columbia. For 

reporting purposes, we refer to the District of Columbia as a State 

throughout our analysis. 

State Medicaid Directors 

To obtain descriptive information on all States’ practices with regard 

to self-declaration of U.S. citizenship, we administered telephone 

surveys to all 51 State Medicaid directors and their staff. We asked 

directors about their States’ self-declaration practices and whether 

their State has a policy instructing eligibility staff to obtain additional 

verification when applicants’ statements appear incomplete, unclear, 

or inconsistent, which some States refer to as a “prudent person 

policy.” We also asked directors to submit any evaluations or audits 

that were conducted within the last 5 years that looked at selfdeclaration of U.S. citizenship for Medicaid. We were able to speak 

with all directors during June and July 2003, giving us an overall 

response rate of 100 percent. 

MEQC Supervisors/ Medicaid Directors 

We administered another telephone survey to the 47 MEQC 

supervisors and/or Medicaid directors in States that permit selfdeclaration of U.S. citizenship during December 2003. We spoke with 

all 47 directors and/or supervisors in these States. Survey questions 

for the 47 Medicaid directors and/or supervisors focused on: 

• Whether MEQC was conducted in a traditional format, under 

a section 1115 waiver, or under an MEQC pilot format during 

fiscal year 2003; 

• The extent to which citizenship statements were checked 

during quality control activities; 

• The types of documentation used to prove statements of U.S. 

citizenship; and 

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 INROD UCT ION 

• Whether, as part of the States’ quality control practices, selfdeclaration of U.S. citizenship was included for review. 

For States operating a traditional MEQC program, we asked if staff 

conducted the required activities, as outlined in the CMS State 

Medicaid Manual. 

CMS Representatives 

We conducted interviews with representatives from the Medicaid 

State Operations group at CMS. These interviews focused on how 

States are permitted to conduct MEQC activities. 

Social Security Administration Management Staff 

In January 2004, we conducted a telephone interview with 

management staff at SSA to determine if statements of U.S. 

citizenship are documented during and throughout the Social Security 

enumeration process and for SSI benefits. We also asked questions on 

the extent to which citizenship data collected for SSA program 

eligibility are shared with State Medicaid agencies. 

Foster Care Directors 

We conducted a Web-based, self-administered survey of State foster 

care directors. All 51 directors responded to our survey during 

October 2003. The survey requested information on whether foster 

care staff document a child’s U.S. citizenship when determining 

eligibility for federally funded foster care maintenance payments. 

TANF Directors 

We conducted a self-administered, Web-based survey of State TANF 

directors. All 51 directors responded to our survey during September 

2003. The survey requested States’ policies on self-declaration of U.S. 

citizenship to qualify for TANF benefits. 

Citizenship Evidence Accepted by CMS or SSA 

As mentioned earlier, DHS, the agency responsible for determining 

citizenship for a person in the United States, does not currently have a 

comprehensive reference list of acceptable evidence. In the absence of 

an official document from DHS, we developed a comprehensive list of 

“accepted evidence” by combining the evidence accepted by CMS19 or 

19 State Medicaid Manual, §§ 3212.3 and 7269.130. 

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INTROD UCT ION 

SSA20 for purposes of documenting citizenship for program eligibility. 

We then compared the forms of evidence States report using to 

document U.S. citizenship for Medicaid and related programs with this 

comprehensive list. See Appendix A for a complete listing of accepted 

evidence used during our analysis. 

We conducted this inspection in accordance with the “Quality 

Standards for Inspections” issued by the President’s Council on 

Integrity and Efficiency. 

20 The SSA Program Operations Manual System, “Establishing U.S. Citizenship for all SSA 

Programs,” GN 00303.300, July 12, 2002. 

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ΔF I NDING S FINDINGS 

Forty-seven States allow self-declaration of U.S. 

citizenship for Medicaid; nearly all of these require 

evidence if statements seem questionable 

Pursuant to the Act, States may 

accept a signed declaration as 

proof of U.S. citizenship from 

applicants seeking Medicaid 

benefits.21 Forty-seven of fifty-one Medicaid directors report that 

their State allows or sometimes allows self-declaration of U.S. 

citizenship. For the four remaining States (Montana, New 

Hampshire, New York, and Texas) directors report that applicants 

must submit documentary evidence to verify U.S. citizenship 

statements. Table 1 displays each State’s policy on self-declaration of 

U.S. citizenship for Medicaid. 

Seven directors report that although their State sometimes allows 

applicants to self-declare U.S. citizenship, documentation is required 

under some circumstances. Four of these directors indicate that 

documentation is required for the aged, blind, and disabled 

populations. Other circumstances in which States sometimes ask for 

documentation include when the applicant was born outside of the 

United States or if information related to the applicant’s place of birth 

does not exist in the State’s vital statistics database. 

With the exception of one State that verifies self-declaration 

statements through its vital statistics database, no other States 

volunteer that they obtain verification of citizenship statements from 

other nonapplicant sources. Further, none of the directors volunteer 

that eligibility staff currently utilize citizenship verification 

information from related programs such as TANF or foster care. 

Nearly all States that allow self-declaration require evidence of U.S. 

citizenship if statements seem questionable during the eligibility process 

Forty-four of the forty-seven States that permit or sometimes permit 

self-declaration report that they have a written or informal “prudent 

person policy” requiring documentation if the statements of the 

applicant seem questionable. Of these, 32 States have a written 

policy to guide staff in these situations. An example of a written 

policy instructs Medicaid eligibility staff that 

21 CMS letter to State Medicaid directors, September 10, 1998. 

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F I NDING S 

Table 1: State Policies on Self-Declaration of Citizenship for Medicaid 

State Allowed Sometimes 

Allowed 

Not 

Allowed 

Prudent 

Person 

Policy 

AL 9 Written 

AK 9 Written 

AZ 9 Written 

AR 9 Informal 

CA 9 Written 

CO 9 None 

CT 9 Written 

DE 9 Informal 

DC 9 None 

FL 9 Written 

GA 9 Written 

HI 9 Informal 

ID 9 Informal 

IL 9 Informal 

IN 9 Informal 

IA 9 Written 

KS 9 Written 

KY 9 Written 

LA 9 Written 

ME 9 Informal 

MD 9 Written 

MA 9 None 

MI 9 Written 

MN 9 Written 

MS 9 Written 

MO 9 Informal 

MT 9 NA 

NE 9 Written 

State Allowed Sometimes 

Allowed 

Not 

Allowed 

Prudent 

Person 

Policy 

NV 9 Written 

NH 9 NA 

NJ 9 Written 

NM 9 Written 

NY 9 NA 

NC 9 Written 

ND 9 Written 

OH 9 Written 

OK 9 Written 

OR 9 Written 

PA 9 Written 

RI 9 Informal 

SC 9 Written 

SD 9 Informal 

TN 9 Informal 

TX 9 NA 

UT 9 Written 

VT 9 Written 

VA 9 Informal 

WA 9 Written 

WV 9 Written 

WI 9 Written 

WY 9 Written

 Totals 40 7 4 -

Written - - - 32

 Informal - - - 12

 None - - - 3 

Source: OIG analysis of State policies on self-declaration of U.S. citizenship, 2004 

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F I NDING S 

when statements of client are incomplete, unclear, or 

inconsistent, or when other circumstances in the particular case 

indicate to a prudent person that further inquiry must be made, 

the worker shall obtain additional verification before eligibility 

is determined. 

The remaining 12 States have unwritten, informal prudent person 

policies requiring additional verification when eligibility staff deem 

statements questionable. 

Medicaid directors report they allow self-declaration to increase access and 

express concern about increased costs if the policy is prohibited 

We asked the 47 State Medicaid directors in States allowing selfdeclaration their reasons for not requiring evidence of U.S. 

citizenship. Twenty-five respondents say that they have been 

encouraged by CMS to simplify their application processes in order to 

reduce barriers to health care access. In addition, 17 respondents 

report that through their posteligibility quality control activities, they 

have not seen a problem with self-declaration of citizenship. 

We asked what costs, if any, Medicaid applicants would incur if all 

were required to provide documentary evidence of U.S. citizenship. 

Twenty-eight of forty-seven directors report that it would delay 

eligibility determination. In addition, 25 directors comment that it 

would result in increased eligibility personnel costs. Twenty-one 

directors also report that it would be burdensome and/or expensive for 

applicants to obtain copies of birth certificates or other 

documentation. 

Federal regulations require Twenty-seven States do not verify the accuracy of U.S. State Medicaid agencies to citizenship claims as part of their posteligibility quality conduct posteligibility quality 

control activities control activities to “eliminate 

or substantially reduce dollar losses resulting from eligibility 

errors.”22 States may conduct MEQC activities in a traditional 

format, under an MEQC pilot format, or as part of a section 1115 

waiver. In fiscal year 2003, 27 of the 47 States that allow selfdeclaration did not conduct quality control activities that included 

verification of statements of U.S. citizenship. 

22 42 CFR § 431.800. 

OE I - 0 2 -03-00190 S E L F - DECL ARATION OF U.S . CI T IZE N S H I P F O R ME D I CAI D 11 
F I NDING S 

F I NDING S 

Of the 20 States that did review statements of U.S. citizenship, 9 did 

so for a nonrepresentative sample of the entire Medicaid population. 

Consequently, some groups that may pose vulnerability to Medicaid 

integrity were not included in the sample of applications that were 

reviewed. See Appendix B for a list of States’ quality control 

activities. 

Three States operating traditional MEQC programs do not conduct required 

quality control activities 

Under traditional MEQC, States are required to verify that sampled 

applicants are U.S. citizens. Three of the eleven States that operated 

a traditional MEQC program and allowed self-declaration in fiscal 

year 2003 did not conduct required eligibility quality control for U.S. 

citizenship. These States report that they did not collect documentary 

evidence to support statements of U.S. citizenship for sampled 

applicants. (See Table 2.) 

Table 2: Medicaid Quality Control on Self-Declaration of U.S. Citizenship

by Type of MEQC Program 

Type of MEQC 

Program 

Does Not Conduct 

MEQC for SelfDeclaration 

Conducts 

MEQC for 

Self-Declaration 

Total 

Number of States 

That Allow SelfDeclaration 

Traditional 3 8 11 

Pilot* 20 8 28 

Waiver 4 4 8 

Overall total 

States 27 20 47 

*In fiscal year 2003, Tennessee operated under both an MEQC pilot and an 1115 waiver. We considered Tennessee 

a pilot program because it conducted MEQC activities under its pilot, which included the entire Medicaid population. 

Source: OIG analysis of State MEQC practices, 2004 

OE I - 0 2 -03-00190 S E L F - DECL ARATION OF U.S . CI T IZE N S H I P F O R ME D I CAI D 12 
F I NDING S 

Twenty MEQC pilot States do not monitor self-declaration of U.S. citizenship 

While operating under an MEQC pilot, States may, but are not 

required to, conduct posteligibility reviews of self-declaration of 

citizenship statements. Twenty of the twenty-eight States that 

permit self-declaration of U.S. citizenship and operated under a pilot 

program in fiscal year 2003 did not obtain documentary evidence to 

support beneficiaries’ statements of U.S. citizenship for any portion of 

their Medicaid population. Eight States conducted quality control on 

self-declarations of citizenship, but seven did so for a 

nonrepresentative sample which accounted for less than 8 percent of 

the Medicaid population. These samples did not include certain 

populations that may pose vulnerability to Medicaid integrity. 

Four section 1115 waiver States do not address self-declaration of U.S. 

citizenship 

While operating under a section 1115 waiver with a quality control 

component, a State may, but is not required to, conduct reviews of 

self-declaration of citizenship statements. Four of the eight States 

that allow Medicaid applicants to self-declare U.S. citizenship and 

operated under section 1115 waivers in fiscal year 2003 did not obtain 

and verify documentary evidence to support statements of U.S. 

citizenship. Of the four section 1115 waiver States that verify 

statements of U.S. citizenship for quality control purposes, two 

conducted MEQC for only a subset of the entire Medicaid population. 

Only one State reports conducting an audit looking at self-declaration of 

U.S. citizenship, and it found vulnerabilities 

We asked States for any quality control audits or evaluations that 

looked at self-declaration of citizenship. Only one State director 

provided an audit on this topic. This audit report found 

vulnerabilities related to the process of self-declaration of U.S. 

citizenship. 

Specifically, the audit, conducted in January 2002 by the Secretary of 

the State of Oregon, found that the State provided full Medicaid 

benefits to 25 beneficiaries (of the sample of 812) who were 

noneligible noncitizens. The audit report concludes that there are 

potential risks involved in allowing applicants to self-declare their 

U.S. citizenship on mail-in applications, which do not allow workers to 

verify the accuracy of statements of U.S. citizenship. They estimate 

OE I - 0 2 -03-00190 S E L F - DECL ARATION OF U.S . CI T IZE N S H I P F O R ME D I CAI D 13 
F I NDING S 

that the risk could result in an annual cost of about $2 million, based 

on a 1 percent estimate of noneligible noncitizens receiving Medicaid 

benefits.23 

Some States use types of evidence that are 

not accepted by CMS or SSA to document 

citizenship for Medicaid 

Four States use forms of evidence that are not accepted by CMS or SSA to 

document citizenship for initial Medicaid eligibility 

As reported earlier, seven States sometimes allow and four States do 

not allow Medicaid applicants to self-declare citizenship. Of these 11 

States, 4 use types of evidence to document citizenship that are not 

accepted by CMS or SSA. Specifically, two States allow the use of a 

school record to document citizenship and two allow use of a family 

Bible as documentation.24 

Seven of eleven States that sometimes allow or do not allow selfdeclaration report accepting documentation that is accepted by CMS 

or SSA. These include public birth records, U.S. passports, and 

naturalization certificates. 

Thirteen States use types of evidence that are not accepted by CMS or SSA 

to verify statements of U.S. citizenship for posteligibility quality control 

purposes 

Thirteen of the twenty States that report conducting quality control to 

verify statements of U.S. citizenship use forms of documentation that 

are not accepted by CMS or SSA. For example, 11 of these 13 States 

report using records of receipt of SSI to verify citizenship. While one 

of the primary sources included in the CMS State Medicaid Manual to 

verify citizenship and alienage declarations is “Record of receipt of 

23 Audit Report: “Department of Human Services Oregon Health Plan Eligibility Review,” 

Report No. 2002-03, January 3, 2002, p. 1. 

24 According to section 7269.1 of the State Medicaid Manual, States may accept evidence of 

continuous residence in the United States prior to June 30, 1948. Among the records 

accepted to prove continuous residence are school records, a marriage license, a voter 

registration card, an insurance policy, military service records, and a Social Security 

number. The directors identified here did not report accepting documentation that was 

dated prior to June 30, 1948. 

OE I - 0 2 -03-00190 S E L F - DECL ARATION OF U.S . CI T IZE N S H I P F O R ME D I CAI D 14 
F I NDING S 

SSI,”25 in discussions with SSA, we found that verification of receipt 

of SSI does not guarantee that the Medicaid applicant or beneficiary 

is a U.S. citizen. Medicaid agencies must take the additional step of 

verifying the Alien/Refugee code in the State Data Exchange report 

files, which provide States with eligibility, payment, and demographic 

data relating to SSI recipients, to substantiate that evidence of U.S. 

citizenship was submitted for SSI eligibility purposes. 

Other examples of documentation that is not accepted by CMS or SSA 

but which State Medicaid directors report using for quality control 

purposes are voter registrations, proof of Medicare Part A, school 

records, children’s birth certificates to prove a parent’s citizenship 

status, marriage licenses, and even other self-declaration statements. 

Medicaid-related programs are more 

likely to document citizenship; their 

verifications may be a useful resource for 

Medicaid 

Medicaid applicants may potentially 

participate in related programs such as 

SSI, foster care, and TANF. We found 

that these related programs are more 

likely than Medicaid to document 

citizenship and most often use evidence that is accepted by CMS or 

SSA to verify this status. These verifications may be a useful 

resource for Medicaid staff. Appendix C provides information on 

related programs’ policies and use of documentation on a State-byState basis. 

United States citizenship is always documented for enumeration and SSI 

The SSA officials report that all applicants must provide documentary 

evidence of U.S. citizenship or legal status in order to receive a Social 

Security number (enumeration) or to qualify for SSI benefits. In some 

cases, SSA’s prior determination of citizenship is accepted as a means 

for documenting U.S. citizenship. However, SSA is currently 

reviewing this policy to ensure that it does not rely on inadequate 

documentation that was submitted for purposes of enumeration and 

SSI in prior years. 

As indicated earlier, in discussions with SSA officials, we found that 

verification of receipt of SSI does not prove U.S. citizenship. 

25 It is important to note that this list does not distinguish between appropriate sources to 

verify U.S. citizenship versus appropriate sources to verify alienage. 

OE I - 0 2 -03-00190 S E L F - DECL ARATION OF U.S . CI T IZE N S H I P F O R ME D I CAI D 15 
F I NDING S 

Eligibility staff must take the additional step of verifying the 

Alien/Refugee code in the State Data Exchange report files. 

Forty-two States document the citizenship status of children receiving Title 

IV-E foster care benefits, as required by the Administration for Children and 

Families 

The Administration for Children and Families requires that foster 

care eligibility staff document U.S. citizenship status for purposes of 

federally funded Title IV-E foster care maintenance payment 

eligibility.26 Forty-two of fifty-one foster care directors report that 

staff document U.S. citizenship when determining eligibility for 

federally funded foster care maintenance. Seven directors report that 

staff sometimes document U.S. citizenship, and two say citizenship is 

never documented. 

Among the seven foster care directors who indicate that U.S. 

citizenship is sometimes not documented, circumstances under which 

no documentation occurs vary significantly. Examples include “the 

rare occurrence when a child falls under category 85, undocumented 

alien emergency situation coverage” and “when a parent or other 

reliable source reports a child is a citizen.” 

Fifteen States document citizenship to determine TANF eligibility 

Similar to requirements for Medicaid, States may permit TANF 

applicants to self-declare U.S. citizenship status as a condition of 

eligibility. Fifteen of fifty-one directors report verifying citizenship for 

TANF eligibility. Twelve directors report that it is their State’s policy 

to sometimes verify applicants’ statements of U.S. citizenship. 

Twenty-four TANF directors report that their State allows selfdeclaration for eligibility purposes. 

Related programs commonly use types of evidence that are accepted by 

CMS or SSA to verify citizenship 

Thirty-five of the forty-nine foster care directors that verify or 

sometimes verify U.S. citizenship for children entering their State’s 

foster care program use types of evidence that are accepted by CMS or 

SSA. The remaining 14 include forms of documentation that are not 

accepted. Examples of these include green cards, Social Security 

26 “ACF Child Welfare Policy Manual – WC Policy Database – Policy Questions & 

Answers,” Question 9, June 4, 2003. 

OE I - 0 2 -03-00190 S E L F - DECL ARATION OF U.S . CI T IZE N S H I P F O R ME D I CAI D 16 
F I NDING S 

numbers, citizenship declarations by parents/caregivers, military 

service records, and family Bibles. 

Twenty of the twenty-seven States that verify or sometimes verify 

U.S. citizenship for TANF eligibility purposes use evidence accepted 

by CMS or SSA. The remaining States report using evidence that is 

not accepted, such as voter registration cards, school records, and/or 

family Bibles. 

In the majority of instances, we found that related programs draw on 

evidence that is accepted by CMS or SSA to verify statements of 

citizenship. In States where related programs both verify statements 

of citizenship and use generally accepted documentation to do so, 

these verifications may be a useful resource for Medicaid. 

OE I - 0 2 -03-00190 S E L F - DECL ARATION OF U.S . CI T IZE N S H I P F O R ME D I CAI D 17 
Δ RECOMME NDA TIONS 

We recognize that there are challenges in providing Medicaid benefits 

expeditiously while ensuring the accuracy of eligibility determinations. 

By their nature, self-declaration policies have inherent vulnerabilities 

in that they can allow applicants to provide false statements of 

citizenship. As such, it is vital to have protections in place to prevent 

such practices. 

Based on the descriptive information we collected from States, we 

conclude that existing safeguards at the point of entry into Medicaid 

and during posteligibility quality control could allow false statements of 

citizenship to go undetected. Below are three recommendations for 

improving safeguards: 

CMS should strengthen posteligibility quality controls in States that allow 

self-declaration 

Currently, 47 States allow self-declaration of citizenship for Medicaid. 

Over half of these never verify citizenship statements as part of their 

posteligibility quality control procedures. In States that do check 

statements, most do so for a subset of the entire Medicaid population. 

More examinations are needed to determine if there are problems 

resulting from this policy. Therefore, CMS should encourage States 

that allow self-declaration of citizenship to conduct reviews on the 

accuracy of these statements. Findings from these reviews could then 

be used to determine the extent to which this policy results in 

inaccurate eligibility determinations. 

CMS should issue a complete list of evidence that States may reference 

when determining eligibility 

Four of the eleven States that require or sometimes require evidence of 

citizenship for initial Medicaid eligibility use types of evidence that are 

not accepted by CMS or SSA. Further, 13 of the 20 States that report 

conducting quality control to verify statements of citizenship use types 

of evidence that are not accepted by CMS or SSA. In its State Medicaid 

Manual, CMS has two lists of evidence that are slightly different, and 

neither is comprehensive. To better ensure that States collect evidence 

that is consistent with CMS standards, CMS should issue a complete 

list of evidence that States may reference when determining eligibility. 

OE I - 0 2 -03-00190 S E L F - DECL ARATION OF U.S . CI T IZE N S H I P F O R ME D I CAI D 18 
R E C O MMENDA T I O N S 

CMS should explore allowing State Medicaid staff to use citizenship 

verifications from other Medicaid-related programs as an additional 

resource 

When looking at related programs including SSI, Title IV-E, and TANF, 

we found that these programs are more likely to verify citizenship as a 

condition of eligibility and, in most cases, use types of evidence that are 

accepted by CMS or SSA. If CMS determines it appropriate, States that 

allow applicants to self-declare citizenship could perform checks on the 

accuracy of these statements using related programs’ verification 

information. This step would not add a burden to applicants and would 

not require the collection of additional documentation. In Appendix C, 

we identify which States and programs verify statements of citizenship 

and use evidence accepted by CMS or SSA. 

AGENCY COMMENTS 

CMS concurred with our recommendations. The agency further 

commented that it has already taken steps to improve safeguards to 

prevent applicants from providing false statements of citizenship. The 

full text of CMS’s comments is included in Appendix D. 

We note several issues with CMS’s current efforts. Specifically, CMS 

explained that, pursuant to Federal regulations, States must verify 

statements of citizenship for sampled active cases as part of their 

posteligibility quality control procedures. We reiterate that this 

regulation applies only to States that operate traditional quality control. 

States that operate under a pilot or a section 1115 waiver with a quality 

control component are not required to verify all elements of eligibility, 

including statements of citizenship as part of their posteligibility case 

file review. 

CMS also commented that States choosing to accept self-declaration of 

citizenship need to have systems in place for some type of posteligiblity 

check to ensure that the self-declaration procedure is reliable. CMS 

stated that it is taking steps to do this by requiring a review of the 

accuracy of eligibility determinations as part of the Payment Error Rate 

Measurement (PERM) project. Currently, the Office of Management 

and Budget is working with CMS to define the scope of the PERM 

project. As of June, no decision has been made regarding the inclusion 

of errors related to Medicaid eligibility determinations. 

OE I - 0 2 -03-00190 S E L F - DECL ARATION OF U.S . CI T IZE N S H I P F O R ME D I CAI D 19 
Δ APPENDIX ~ A

Types of Evidence Accepted by CMS or SSA to Document U.S. 

Citizenship 

Documentation Type CMS SSA 

A birth certificate showing birth in 

the United States 9 9 

Religious record of birth recorded 

in the United States or its 9 9 

territories within 3 months of 

birth, which indicates a U.S. 

place of birth 

United States passport 9 9

Form FS-240 (Report of Birth 

Abroad of a Citizen of the United 9 9 

States) 

Form FS-545 (Certification of 9 9

Birth) 

U.S. Citizen I.D. Card Form I-97 

(United States Citizen 9 9 

Identification Card) 

Form N-550 and N-570 

(Certificate of Naturalization) 9 9 

Forms N-560 and N-561 9 9

Evidence of continuous 

residence in the United States 

prior to June 30, 1948 (including 

school records; marriage license; 

voter registration card; insurance 9

policy; military service records; 

Social Security number issued 

prior to June 30, 1948, etc.) 

Record receipt of SSI* 9 9

Bureau of Vital Statistics, local 

government, hospital, or clinic 9 

records of birth and parentage 

Court records of parentage, 9 

juvenile proceedings, or child 

support 

 Sources: CMS State Medicaid Manual §§ 3212 and 7269 and the SSA Program Operations Manual System: GN 00303.300 

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APP E N D I X ~A 

Documentation Type CMS SSA 

American Indian Card (first 

issued by INS in 1983) 9 9 

Form DS-1350 (Certification of 

Report of Birth) issued by the 

State Department 9 

Northern Mariana Identification 

(NMI) Card, first issued by INS in 

1987, to identify naturalized 

citizens born in the NMI before 

November 3, 1986 9 9 

Evidence of civil service 

employment by the U.S. 

Government before June 1, 1976 9 

 Sources: CMS State Medicaid Manual §§ 3212 and 7269 and the SSA Program Operations Manual System: GN 00303.300 

*Note: In discussions with SSA, we found that verification of receipt of SSI alone does not guarantee 

that the Medicaid applicant or beneficiary is a U.S. citizen. Medicaid agencies must take the 

additional step of verifying the Alien/Refugee code in the State Data Exchange report files. 

Therefore, while CMS does accept this form of documentation, we determined that this might not 

prove U.S. citizenship.

OE I-02-03-00 190 S E L F - DE C L ARAT I ON O F U . S. CI T IZEN S H I P F O R MEDIC AID 21 
Δ APPENDIX ~ B 

Fiscal Year 2003 MEQC in the 47 States Allowing Self-Declaration of 

U.S. Citizenship 

State CMS MEQC 

Categorization 

Conducts Some MEQC 

On Self-Declaration Of U.S. 

Citizenship 

Alabama 

Alaska 

Arizona 

Arkansas 

California 

Colorado 

Connecticut

Delaware 

District of Columbia 

Florida 

Georgia 

Hawaii 

Idaho 

Illinois 

Indiana 

Iowa 

Kansas 

Kentucky 

Louisiana 

Maine 

Maryland 

Massachusetts 

Michigan 

Minnesota 

Mississippi 

Missouri 

Nebraska 

Traditional 

Pilot 

Waiver 

Waiver 

Pilot 

Pilot 

Traditional 

Pilot 

Pilot 

Traditional 

Traditional 

Waiver 

Pilot 

Pilot 

Pilot 

Pilot 

Pilot 

Pilot 

Pilot 

Traditional 

Waiver 

Waiver 

Traditional 

Waiver 

Traditional 

Waiver 

Pilot 

Yes 

No 

Yes 

Yes 

Yes 

No 

Yes 

No 

No 

Yes 

No 

Yes 

No 

Yes 

Yes 

No 

No 

No 

No 

No 

Yes 

No 

Yes 

No 

Yes 

No 

No 

OE I-02-03-00 190 S E L F - DE C L ARAT I ON O F U . S. CI T IZEN S H I P F O R MEDIC AID 22 
APP E N D I X ~B 

State CMS MEQC 

Categorization 

Conducts Some MEQC 

On Self-Declaration Of U.S. 

Citizenship 

Nevada 

New Jersey 

New Mexico 

North Carolina 

North Dakota 

Ohio 

Oklahoma 

Oregon 

Pennsylvania 

Rhode Island 

South Carolina 

South Dakota 

Tennessee 

Utah 

Vermont 

Virginia 

Washington 

West Virginia 

Wisconsin 

Wyoming 

Pilot 

Pilot 

Pilot 

Pilot 

Traditional 

Pilot 

Traditional 

Waiver 

Pilot 

Traditional 

Pilot 

Pilot 

Pilot* 

Pilot 

Traditional 

Pilot 

Pilot 

Pilot 

Pilot 

Pilot 

No 

No 

No 

No 

Yes 

No 

No 

No 

Yes 

Yes 

Yes 

No 

Yes 

Yes 

Yes 

No 

No 

No 

Yes 

No

 Total Traditional 

Total Pilot 

Total Waiver 

Total Yes 

Total No 

11 

28 

8 

-

-

-

-

-

20

27 

Source: OIG analysis of State MEQC practices, 2004 

*In fiscal year 2003, Tennessee operated under both an MEQC pilot and an 1115 waiver. We considered Tennessee a 

program because it conducted MEQC activities under its pilot, which included the entire Medicaid population. 

OE I-02-03-00 190 S E L F - DE C L ARAT I ON O F U . S. CI T IZEN S H I P F O R MEDIC AID 23 
Δ APPENDIX ~ C 

Related Programs Policies on Self-Declaration and Their Use of 

Documentation Accepted by CMS or SSA: A Guide for Medicaid 

Eligibility Staff 

State Medicaid TANF 

TANF Uses 

Evidence 

Accepted by CMS 

or SSA 

Foster 

Care 

Foster Care 

Uses Evidence 

Accepted by 

CMS or SSA 

AL ▲ Δ Yes ● No 

AK Δ Δ Yes ● Yes 

AZ ▲ Δ No ● Yes 

AR ▲ ▲ NA ● Yes 

CA Δ ● Yes ● Yes 

CO ▲ ▲ NA ● Yes 

CT ▲ Δ No Δ No 

DE ▲ ● No ● Yes 

DC ▲ ▲ NA ● Yes 

FL Δ ▲ NA ● No 

GA ▲ ▲ NA ● No 

HI ▲ ● Yes ● No 

ID ▲ ▲ NA ● No 

IL ▲ Δ Yes ● Yes 

IN Δ ● Yes ● Yes 

IA ▲ Δ Yes ● Yes 

KS ▲ ▲ NA ● Yes 

KY ▲ ▲ NA ● No 

LA ▲ ▲ NA Δ Yes 

ME ▲ ▲ NA ● Yes 

MD ▲ Δ Yes ● Yes 

MA ▲ Δ No ▲ NA 

MI ▲ Δ Yes ● Yes 

MN ▲ ▲ NA ▲ NA 

MS Δ ▲ NA ● Yes 

MO ▲ Δ Yes Δ Yes 

MT ● ● Yes ● Yes 

NE ▲ ▲ NA ● No 

OE I-02-03-00 190 S E L F - DE C L ARAT I ON O F U . S. CI T IZEN S H I P F O R MEDIC AID 24 
 APP E N D I X C 

State Medicaid TANF 

TANF Uses 

Evidence 

Accepted by 

CMS or SSA 

Foster 

Care 

Foster Care 

Uses Evidence 

Accepted by 

CMS or SSA 

NV ▲ ● Yes ● Yes 

NH ● ● No ● Yes 

NJ Δ ● No Δ Yes 

NM ▲ ▲ NA Δ No 

NY ● ● Yes ● Yes 

NC ▲ ▲ NA ● No 

ND ▲ ● Yes Δ No 

OH ▲ ● Yes ● Yes 

Ok ▲ ▲ NA ● Yes 

OR ▲ ▲ NA ● Yes 

PA ▲ Δ No ● Yes 

RI Δ ● Yes ● Yes 

SC ▲ ▲ NA ● Yes 

SD ▲ ▲ NA ● Yes 

TN ▲ ▲ NA ● Yes 

TX ● ● Yes Δ No 

UT ▲ ▲ NA ● No 

VT ▲ Δ Yes ● Yes 

VA ▲ ▲ NA ● Yes 

WA ▲ ▲ NA ● Yes 

WV ▲ ▲ NA ● Yes 

WI ▲ ● Yes ● Yes 

WY ▲ ● Yes ● No

 Total ▲ 40 24 - 2 -

Total Δ 7 12 - 7 -

Total ● 4 15 - 42 -

Total Yes - - 20 - 35

 Total No - - 7 - 14

 Total NA - - 24 - 2

 Source: OIG analysis of related program policies on self-declaration of U.S. citizenship, 2004 

* Because SSA always verifies the citizenship status of applicants for a Social Security number or for 

SSI, a State-by-State description of this policy does not appear in this table. 

▲ Denotes a State that reports permitting self-declaration of U.S. citizenship or reports not requiring 

evidence of citizenship to qualify for federally funded benefits. 

Δ Denotes a State that reports sometimes permitting self-declaration of U.S. citizenship. 

● Denotes a State that reports never permitting self-declaration or requiring evidence of U.S.

citizenship to qualify for this federally funded benefit.

OE I-02-03-00 190 S E L F - DE C L ARAT I ON O F U . S. CI T IZEN S H I P F O R MEDIC AID 25 
Δ APPENDIX ~ D 

OE I-02-03-00 190 S E L F - DE C L ARAT I ON O F U . S. CI T IZEN S H I P F O R MEDIC AID 26 
APP E N D I X ~D 

OE I-02-03-00 190 S E L F - DE C L ARAT I ON O F U . S. CI T IZEN S H I P F O R MEDIC AID 27 
APP E N D I X ~D 

OE I-02-03-00 190 S E L F - DE C L ARAT I ON O F U . S. CI T IZEN S H I P F O R MEDIC AID 28 
Δ END NOTES ACKNOWLEDGMENTS 

This report was prepared under the direction of Jodi Nudelman, Acting 

Regional Inspector General for Evaluation and Inspections in the New 

York Regional Office. Other principal Office of Evaluation and 

Inspections staff who contributed include: 

Ellen Vinkey, Team Leader 

Christi Macrina, Project Leader 

David Rudich, Program Analyst 

Linda Ragone, Deputy Regional Inspector General, Region III 

Tricia Davis, Director, Medicare and Medicaid Branch 

Elise Stein, Director, Public Health and Human Services 

Linda Hall, Program Specialist 

Barbara Tedesco, Mathematical Statistician 

OE I-02-03-00 190 S E L F - DE C L ARAT I ON O F U . S. CI T IZEN S H I P F O R MEDIC AID 29