MANUAL TRANSMITTAL
Arkansas Department of Health & Human Services
Division of County Operations
Policy Directive Issuance Number: MS 06-08
Medical Services Policy Manual Issuance Date: September 15, 2006
From: Joni Jones, Director Expiration Date: Until Superseded
Subj: Procedures Developed with the Division of Health related to Citizenship Verification for Medicaid Applications Taken at Local Health Units
The Division of County Operations has coordinated with the Division of Health to assist with obtaining verification of citizenship for Medicaid applications taken at the local health units. The Division of Health has issued procedures to the local Health Units for obtaining verification of citizenship for Family Planning Waiver and TB Medicaid applicants and submission to the local DHHS county office.
The local Health unit will request citizenship verification from applicants declaring to be U.S. citizens prior to submitting the application to the local DHHS county office. Identity verification will also be requested at the time of application. The applicant will be allowed 10 days to provide verification. If verification is provided, the worker will sign and date the verification acknowledging that it has been viewed and a copy will be forwarded to the county office with the application and other required forms.
Also included with the application and required forms will be form DOH-49, Checklist for Citizenship & Identification (copy attached). The local Health Unit worker will check whether or not the citizenship verification requirement has been met and identify what type of documentation was used. The worker will also indicate on the form if there is a Food Stamp case in which the applicant is or was included. Identity documentation may be available in that case.
Note: This process does not apply to Presumptive eligibility (PE) and SCHIP Pregnant Women applicants. The local health units will refer individuals who declare not to be U.S. citizens, applicants with the permanent residence card, resident alien card and green cards to DHHS to apply for family planning waiver services.
Upon receipt of the Medicaid applications from the local Health Unit, the worker will review form DOH-49, Checklist for Citizenship and Identification, to determine if the
citizenship verification requirement has been met. If the requirement has been met and all other needed information has been provided, the application may be approved. If the requirement has not been met, the worker will first check to see if there is an existing Food Stamp, TEA or Medicaid case, which might include same or all of the required documentation. If not available, the worker will send a 10-day notice to the applicant requesting needed information. The individual will be given sufficient time to provide the verification as long as an attempt is being made to obtain it. If it is determined that the individual is not making an attempt to get the needed verification, it will result in denial of Medicaid for the adult or closure of the adult’s Medicaid case. The worker will notify the local health unit of the approval or denial. Notification can be done via email, returning the Checklist (DOH-49) or any other procedures established between the local county office and health unit.
Inquiries to: Judy Key, 501-682-8259
Carmen Banks, 682-8258
Carla Droughn, 501-682-8254
Dona Young, 501-682-1562
ARKANSAS DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF HEALTH
MEMORANDUM #_________________
TO: All Local Health Units and Regional Offices
FROM: Carolyn Bradley, Management Project Analyst, Third Party Reimbursement
DATE: August 23, 2006
SUBJECT: Identity and Citizenship Mandatory Requirements for Family
Planning Waiver (FPW) and Tuberculosis (TB) Medicaid Applicants
Effective upon receipt, citizenship and identity must be verified on all Medicaid applicants before receiving Family Planning Waiver and TB Medicaid through the Arkansas Medicaid Program. Note: Presumptive eligibility (PE) and SCHIP Pregnant Women applicants are exempted from this requirement.
If a FPW applicant declares she is not a U.S. citizen, refer her to the local DCO County Office to apply for the Family Planning Waiver. This includes those applicants with the permanent residence card, resident alien card and green cards. For TB applicants who do not declare U.S. citizenship, verification of identity and documentation of alien status must be provided. DCO will also make the determination for TB applicants based on the information received.
Once identity and citizenship are verified and documented by the local Division of County Operations (DCO) county office, it will not be necessary to repeat documentation if the patient re-applies for Medicaid.
The Local Health Units will follow the procedures below to meet the mandatory requirements.
Family Planning Waiver and TB Medicaid applicants will need to provide verification of identity at the time of completing the Application for Family Planning Assistance (DCO-64) or Tuberculosis (TB) Medicaid – Application for Assistance (DCO-133). The following documents are acceptable evidence of ID as long as a photograph of the person is on the document:
a. Driver’s License or other state-issued driver’s license
b. Any state-issued ID card
c. School ID card
d. U.S. Military card
e. Documents listed in Step III, Section A, ‘Primary Documentation’
(Note: If the expiration date has expired, the ID is still acceptable.)
DISPOSITION: Make a copy and place in the front, side pocket of the Women’s Health Volume and the front of the TB Manual until further notice.
1. DOH personnel will make a copy of the ID. If the copy is not legible because of the copier, write the illegible information on the copy, sign and date the copy verifying that DOH staff viewed the card and information.
2. If the applicant does not have proof of identity at the time of application, complete the DCO-64 or DCO-133 and ask the applicant to return the information within 10 calendar days.
a. If the applicant returns proof of identity within 10 days, make a copy and forward the DCO-64 or DCO-133, SSN Notification form, proof of ID, proof of citizenship (if available), Checklist for Citizenship & Identification (DOH-49) and other pertinent forms (such as EMS-662 and proof of insurance, if applicable) to the local DCO county office in the normal process. Note: An initial supply of the DOH-49 is included. Order additional ones from Central Supply, as needed.
b. If the applicant does not return proof of identity within 10 days, forward the DCO-64 or DCO-133, SSN Notification form, proof of citizenship (if available), DOH-49 and other pertinent forms (such as EMS-662 and proof of insurance, if applicable) to the local DCO county office in the normal process.
c. If the applicant is the head of the household and has a Food Stamp (FS) case, this can be indicated on the DOH-49. The FS Program is required to verify identity on each casehead. To identify a FS case:
1. Check the Medicaid WSSN screen.
2. Look for Category ’05.’
3. Make sure the Food Stamp case number is the same as the FPW or TB applicant’s SSN. (If the case number does not match, your applicant is not the casehead in the FS case, and proof of identity cannot be established.)
4. If the FS case number matches the FPW or TB applicant’s SSN, make sure to indicate this on the DOH-49.
Be sure the DOH-49 is completed to correctly communicate to DCO whether or not identity is verified.
Family Planning Waiver and TB Medicaid applicants will need to provide verification of U.S. citizenship before Medicaid is approved.
Medicare recipients meet the citizenship requirement through the Social Security Administration (SSA) process. Therefore, get a copy of the patient’s Medicare card (the red, white and blue card) or any documentation from SSA showing he/she is receiving Medicare,
Attach to the family planning or TB Medicaid application along with the other requirements — identity, completed DOH-49, etc. No further verification is needed for citizenship.
The Local Health Units will use the following procedure to obtain proof of citizenship for Family Planning Waiver and TB Medicaid applicants:
1. At the time of completing the DCO-64 or DCO-133, ask the patient for proof of citizenship (a birth certificate is the most prevalent document for most people). Other acceptable evidence of citizenship is outlined in Step III.
Note: In situations in which the birth name is not the same as the current name, get an explanation from the applicant of the name change and document the information.
2. If the birth certificate is not available at the time of application, and the applicant was born in Arkansas, the Local Health Unit will access the Arkansas birth records through the Encounter Management System (EMS) to verify citizenship. Contact Gwen White at 501-661-2164 for instructions for accessing the Arkansas birth records through the Encounter Management System.
Note: It is very important that the applicant’s exact name at birth, including maiden name, be entered into the EMS.
a. If citizenship is verified through the EMS, make a copy of the verification and attach to the DCO-64 or DCO-133. On the DOH-49, indicate that citizenship is verified through the Arkansas Vital Statistics Birth Records.
b. Send the completed DOH-49, along with the DCO-64 or DCO-133 and other pertinent information (EMS-662, if applicable, SSN Notification form, proof of ID, etc.) to the local DCO county office in the normal process.
c. If unable to verify citizenship through the Arkansas Vital Statistics Birth Records (e.g., the spelling provided by applicant does not match birth record), hold the application for 10 calendar days and inform the applicant to provide a birth certificate or the correct spelling of his/her name to the LHU. A file should be created and kept separate from the pending applications.
Also, check the WSSN or WHDX screen to determine if the applicant has received TEA or Medicaid in a previous case record as a dependent—200 suffix (so that DCO can check for a birth certificate in the previous case record). If so, indicate this on the DOH-49.
d. If the applicant does not verify citizenship, send the completed DOH-49, along with the DCO-64 or DCO-133 and other pertinent information (EMS-662), if applicable, SSN Notification form, proof of ID, etc.) to the local DCO county office in the normal process. DCO will send the applicant an official 10-day notice to provide verification of citizenship. If not provided, the application will be denied.
3. If applicant was born in another State, and states that he/she can provide a birth certificate, allow him/her 10 calendar days to provide it.
a. The Local Health Unit must hold the DCO-64 or DCO-133 for 10 calendar days.
b. If the applicant does not return proof of citizenship, forward the DCO-64 or DCO-133, SSN Notification form, proof of identity (if available), DOH-49 and other pertinent forms (such as EMS-662 and proof of insurance, if applicable) to the local DCO county office in the normal process. (Always keep a copy of the information sent to DCO in the patient’s record.)
c. Inform the DCO county office on the DOH-49 that proof of citizenship is not attached. Check the WSSN or WHDX screen to determine if the applicant has received TEA or Medicaid in a previous case record as a dependent—200 suffix (so that DCO can check for a birth certificate in the previous case record). If so, indicate this on the DOH-49.
The local DCO county office will send an official 10-day notice to the applicant requesting proof of citizenship. If not received within the 10-day notice period, DCO will deny the application, as proof of citizenship was not provided.
d. If an applicant who was born in another State informs you that he/she cannot get proof of citizenship, document the patient’s record and charge according to the sliding fee scale. No application will be taken.
4. If the applicant meets citizenship through the process of naturalization, obtain a copy of one of the acceptable evidence listed in Step III of this Section and submit with the DCO-64 or DCO-133.
The Local Health Units will inform all applicants that if their Medicaid application is denied, they may be asked to pay for the services received according to a sliding fee scale. The attached “Notice To All Family Planning Waiver Medicaid Applicants” should be posted in each LHU, and at the LHU Administrator’s discretion, given to each applicant. If the application is denied, at the next visit create and present the patient with the bill. Make sure the comment section reflects that the services were provided in the previous visit. Note: Make copies of the attached Notice to post.
The LHU Administrator should contact the DCO County Administrator to initiate local procedures in which DCO will notify the DOH Local Health Units when a FPW or TB application is denied (i.e., e-mail, fax, etc.). This should assist the LHU in processing the pending files.
Any person born in the United States is considered a citizen. Persons born abroad are considered U.S. citizens when at least one of the parents is a U.S. citizen. Also, a person who is a U.S. national (born in one of the U.S. territories—Puerto Rico, Guam, Virgin Islands, Northern Mariana Islands American Samoa, Swaim Islands) is a U.S. citizen. People who are not citizens or nationals can become U.S. citizens through the process of naturalization.
To establish U.S. citizenship, the Arkansas Medicaid Program will accept the following documents as evidence of citizenship. The acceptable evidence is based on a hierarchy, with the primary documentation as the highest level of reliability. Primary documents establish both U.S. citizenship and identity. Seek the documents in the order listed below:
A. Primary Documentation (highest reliability)
a. U.S. Passport
b. Certification of Naturalization (Department of Homeland Security (DHS) Forms N-550 or N-570)
c. Certificate of U.S. Citizenship (DHS Forms N-560 or N-561)
B. Secondary Documentation
d. U.S. Birth Certificate
e. Certification of Birth issued by the Department of State (Form DS-1350)
f. Report of Birth Abroad of a U.S. Citizen (Form FS-240)
g. Certification of Birth Abroad (FS-545)
h. U.S. Citizen I.D. Card (DHS Form I-197)
i. An American Indian Card issued by DHS 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)
j. Final Adoption Decree
k. Evidence of Civil Service Employment by the U.S. government before June 1976
l. An Official Military Record of service showing a U.S. place of birth
m. 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)
C. Third Level Documentation
n. Extract of U.S. Hospital Record of Birth established at the time of the person’s birth and created at least 5 years before the initial application date and indicates a place of birth
o. Life or Health or Other Insurance Record showing a U.S. place of birth and created at least 5 years before the initial application date
D. Fourth Level Documentation (lowest reliability)
p. Federal or State Census Record showing U.S. citizenship or a U.S. place of birth
q. Institutional admission papers from a nursing home, skilled nursing care facility or other institution and created at least 5 year before the initial application date and indicates a U.S. place of birth
r. Medical (clinic, doctor, or hospital) record and created at least 5 years before the initial application date and indicates a U.S. place of birth, unless the application is for a child under age 5
s. Other documents created at least 5 years before the application for Medicaid. These documents are Seneca Indian tribal census record, Bureau of Indian Affairs tribal census records 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 5 years after the person’s birth or a statement signed by the physician or midwife who was in attendance at the time of birth.
Written Affidavits should only be used in rare circumstances and the following rules must apply:
If you have any questions, please contact Carolyn Bradley at 501-280-4813 or Brad Planey at 501-661-2531. Questions regarding the Encounter Management System should be directed to Gwen White at 501-661-2164.
Checklist
for Citizenship & Identification
Identification verified? ___Yes ___No If Yes, How?__________ (Attach Copy)
Driver’s License, State-Issued ID Card, School ID Card, U.S. Military Card.
NOTE: U.S. Passport, Certification of Naturalization (N-550 or N-570), Certificate of U.S. Citizenship (N-560 or N-561) will verify both identity and citizenship.
___U.S. Passport ___Certificate of Naturalization (N-550 or N-570)
___U.S. Birth Certificate ___Certificate of U.S. Citizenship (N-560 or N-561)
___Certification of Birth Abroad ___Final Adoption Decree
___Official Military Record ___Life or Health Insurance Record showing place of
(Record must show the place of birth.) birth (Record must be at least 5 years old.)
___Medicare Recipients ___U.S. Hospital Record of Birth
(Copy of Medicare card attached.) (Must be at least 5 years old.)
___Other (See policy for other ___LHU verified through the Arkansas Vital Statistics
acceptable documentation.) Birth Records (Copy of birth verification attached.)
_______________________
NOTE: A COPY OF THE CITIZENSHIP DOCUMENTATION CHECKED ABOVE MUST BE ATTACHED TO THE FPW or TB MEDICAID APPLICATION.
CITIZENSHIP and/or ID DOCUMENTATION IS NOT ATTACHED:
____Applicant did not provide proof of ID/Citizenship — Send 10-day notice of action.
(Circle One or Both)
_____Applicant was included as a dependent in a previous case record in the local DCO County
Office — Medicaid case number & month/year applicant last received TEA or Medicaid as
a dependent (200 suffix). Check your DCO files for birth certificate.
_________________________ ________
(Case Number) (mo/yr)
_____Applicant has Food Stamp case — Check for proof of Identity.
ADDITIONAL COMMENTS:_______________________________________________________
_______________________________________
Signature of DOH Personnel & Date
_______________________
Phone Number
DIVISION OF HEALTH
PURPOSE:
The Checklist for Citizenship & Identification (DOH-49) is a communication form used by DOH’s Local Health Units to inform the Division of County Operations (DCO)’s local county offices of the citizenship and identity status of Family Planning Waiver and TB Medicaid applicants.
The purpose of the Checklist is to promote clear communication between the Divisions to ensure that all applicants who are eligible for Family Planning Waiver and TB Medicaid will receive Medicaid benefits in a timely manner.
INSTRUCTIONS:
Patient’s Name: Self-explanatory.
Identification Verified: Self-explanatory.
Citizenship Documentation: Check Yes or No; if Yes, check the type of documentation used to verify citizenship.
___Enter a check 
if
the applicant did not provide proof of ID/Citizenship — DCO will send an
official 10-day
notice of action. If not provided, application will be denied.
___ Enter a check if
the applicant was included as a dependent in a previous case record in the local
DCO
county office.
___ Enter a check if
the applicant has an open or closed Food Stamp case.
Signature of DOH Personnel & Date: Self-explanatory.
Phone Number: Self-explanatory.
Stamp of Local Health Unit: Self explanatory.
If your Family Planning Medicaid application is denied, you may be asked to pay for today’s services according to a sliding fee scale.
Thank you.