Hierarchy of Acceptable Documents to Prove Citizenship and Identity for Medicaid Eligibility
1. Acceptable primary documentation (documents that provide evidence of both citizenship and identity where no other information is required) include:
A U.S. Passport
A Certificate of Naturalization (DHS Forms –550 or –570)
A Certificate of U.S. Citizenship (DHS Forms –560 or –561)
2.Acceptable secondary documentation that verifies citizenship only (an identity document is also required):
A U.S. birth certificate (at state option, data matches with a State Vital Statistics Agency may be used in place of a birth certificate)
A Certification of Birth issued by the Department of State (Form DS-1350)
A Report of Birth Abroad of a U.S. Citizen (Form FS-240)
A Certification of Birth Abroad (Form FS-545)
A U.S. Citizen I.D. card (DHS Form I-197)
An American Indian Card issued by the Department of Homeland Security with the classification code “KIC” (issued by DHS to identify U.S. citizen members of the Texas Band of Kickapoos living near the U.S./Mexican border)
Final adoption decree
Evidence of civil service employment by the U.S. government before June 1976
An official military record of service showing a U.S. place of birth
A Northern Mariana Identification Card, (issued by the INS to a collectively naturalized citizen of the United States who was born in the Northern Mariana Islands before November 4, 1986)
3. Acceptable third-level documentation to verity proof of citizenship only (acceptable when primary evidence cannot be obtained within the reasonable opportunity period specified by the state and secondary evidence does not exist or cannot be obtained). Proof of identity is also required.
Extract of U.S. hospital record of birth established at the time of the person’s birth and created at least five years before the initial application date and indicating a U.S. place of birth.
Life or health or other insurance record showing a U.S. place of birth and created at least five years before the initial application date.
[7/07 update] A
religious record recorded in the U.S. within three months of birth,
showing a U.S. place of birth.
[7/07 update] An early school record showing a U.S. place of
birth.
4. Acceptable fourth-level documentation for proof of citizenship only (only provides proof of citizenship when secondary or third-level documents do not exist or cannot be obtained). Proof of identity is also required:
Federal or state census record showing U.S. citizenship or a U.S. place of birth.
Institutional admission papers from a nursing home, skilled nursing care facility or other institution, created at least five years before the initial application date and indicating a U.S. place of birth.
Medical (clinic, doctor or hospital) record created at least five years before the initial application date (unless the application is for a child under 5) and indicating a U.S. place of birth.
Other document created at least five years before the application
for Medicaid. These documents are: Seneca Indian tribal census record,
Bureau of Indian Affairs tribal census record of the Navaho Indians,
U.S. State Vital Statistics official notification of birth registration,
an amended U.S. public birth record that is amended more than five years
after the person’s birth or a statement signed by the physician
or midwife who was in attendance at the time of birth, and [7/07
update] the Bureau of Indian
Affairs Roll of Alaska Natives.
Written affidavit, which may be used only in rare circumstances when
citizenship cannot be proven in another way. At least two affidavits
are required
by individuals who have personal knowledge of the event(s) establishing
citizenship and who can prove their own citizenship and identity (one
cannot be related to the applicant/recipient). If information exists
that explains why documentary evidence cannot be obtained or does not
exist they affidavit must contain this information. The state must obtain
a separate affidavit from the applicant/recipient or guardian/representative
explaining why the evidence does not exist or cannot be obtained. All
affidavits are signed under penalty of perjury.
Acceptable documents to prove identity only (an acceptable citizenship document is also required) include:
A current state driver’s license bearing the individual’s picture or a state identity document with the individual’s picture
Certificate of Indian Blood, or other U.S. American Indian/Alaska Native tribal document
A school identification card with a photograph of the individual
U.S. military card or draft record
Identification card issued by the federal, state or local government with the same information included on the driver’s license
Military dependent’s identification card
Native American Tribal document
U.S. Coast Guard Merchant Mariner card
At state discretion, data matches with other agencies can be used to verify identify such as those with federal or state governmental, public assistance, law enforcement or corrections agencies. Such agencies may include food stamps, child support, corrections, juvenile detention, motor vehicle or child protective services.
For children under 16 years of age, in addition to the above documents that may be available to the youth, an affidavit signed under penalty of perjury by a parent of guardian may also attest to the child’s identity.
Judge David L. Bazelon Center for Mental Health Law
1101 15th Street, NW, Suite
1212
Washington, DC 20005
