Consider any person born in the United States to be a citizen. People born abroad are considered U.S. citizens when at least one of the parents is a U.S. citizen. Also consider a person who is a U.S. national the same as a U.S. citizen. A U.S. national is a person who is born in one of the U.S. territories. The U.S. territories include:

• Puerto Rico
• Guam
• The Virgin Islands
• The Northern Mariana Islands
• American Samoa
• The Swain Islands

People who are not citizens or nationals can become citizens through the process of naturalization.

Note: Citizens of the Marshal Islands are under a Compact of Free Association with the

United States. They are free to travel to and from the U.S. without a visa. They

are not U.S. citizens, nor are they under an alien status. For Medicaid purposes,

they are not eligible, except for emergency services.

If a caseworker sent a ten day notice to provide the requested verification and received no response, then action may be taken to deny the application or close the open case for failure to verify citizenship. If citizenship has been verified for any members of the application or open Medicaid do not deny the application or close an open case for failure to verify citizenship. Notice and appeal rights must be given to applicants/recipients if the caseworker should deny for failure to provide this requirement. If the applicant/recipient tries in good faith to present satisfactory documentation, but is unable because the documents are not available, the case worker should assist the individual in securing these documents. If the applicant/recipient cannot obtain the necessary documents and needs assistance (i.e. homeless, mentally impaired, or physically incapacitated), and lacks someone who can act on their behalf, the case worker should assist the applicant or recipient to document U.S. citizenship.

"Public Charge" has been a part of U.S. immigration law for more than 100 years as grounds for inadmissibility and deportation. Identification by the Immigration and Naturalization Service (INS) as a public charge can be grounds for denying admission into the United States, for denying an application for permanent resident status, and in rare cases for deportation.

In 1999, the Justice Department issued regulations to clarify that receipt of most forms of Medicaid would not result in a public charge finding. To be considered a public charge by the INS, an alien must:

• Have become or be likely to become primarily dependent on the government for survival through receipt of public cash assistance, or

• Be institutionalized at government expense in a long-term care facility.

Institutionalization in a long-term care facility includes residing in a nursing home or mental health institution. Short-term institutionalization for rehabilitation is not considered as public charge.

The receipt of cash assistance or being institutionalized for long-term care does not automatically cause the individual to be considered a public charge. The INS also considers a number of other factors, such as the individual's age, health, financial status, education, and skills. Each determination is made on a case by case basis.

Before a Medicaid application can be approved, the individual must provide documentation of alien status. In addition to providing alien documentation, all aliens must provide verification of their identity. If the documentation provided does not contain a photograph, another form of identification must be obtained.

If the alien does not have any documentation, refer the individual to the Immigration and Naturalization Service (INS) to obtain proof of status. Provide the individual with a 10-day written notice requesting the documentation, and extend the 10-day notice if additional time is needed. The INS address for applicants in Arkansas is:

Immigration and Naturalization Service

Attn: Status Verifier/SAVE

701 Loyola Avenue, Room T-8011

New Orleans, LA 70113

If the individual does not provide necessary documentation of alien status for the person requesting Medicaid coverage, the individual will be eligible for emergency services only. ([MS 6780].)

Note: INS does not require children under age 14 to have documentation of their alien status. Therefore, if the adult who is applying for benefits has a documented legal alien status and attests to the child's legal status, the adult's statement is sufficient proof of the child's alien status.

INS requires children aged 14 through 17 to have documentation, but they are not required to carry it on their persons. The Immigration and Nationality Act (INA) requires all aliens 18 or older to carry INS documentation on their persons at all times.

When an individual's INS documentation appears valid but does not have the necessary coding to show the alien's status, or the entry or admission date is missing, verification of the alien's status can be obtained through SAVE's automated database, the Alien Status Verification Index (ASVI).

To access the ASVI:

• Using a touch-tone phone, dial the toll-free system number, 1-800-365-7620.

• Enter the access code, then press the pound (#) sign when instructed by the recorded message.

• Enter the alien registration number when instructed by the recorded message. The alien registration number is a series of digits preceded by the letter "A." Do not enter the "A." If the number is less than nine digits, use zeros at the beginning of the number to make it nine digits. (E.g., if the number is "A12345" enter it as "000012345.")

If a record for the alien is found, the ASVI system will give the alien's:

• Registration number.
• Verification number.
• Last and first name, spelled out.
• Date of birth.
• Status code.
• Country of birth code.
• Social Security number.
• Date of entry.

If no record is found for the alien, the ASVI system will instruct you to "institute secondary verification." When this message is received, use form G-845, Document Verification Request, to get information from INS.

Secondary documentation is the process for obtaining status information from the INS when using form G-845, Document Verification Request, and its supplement.

Obtain secondary documentation only when:

• SAVE instructs you to do so.

• The documentation the individual provided shows an eligible status, but the document itself is expired or appears questionable or not genuine.

• The documentation is a receipt showing that the alien has an eligible status but has applied to INS for a replacement card.

• The INS documentation appears to be genuine and the alien claims to have an eligible status, but necessary codes or dates are missing from the card.

Until verification is received from the INS indicating the individual is a qualified alien, the individual should be treated as a nonqualified alien.

To be eligible for Medicaid, aliens must meet the categorical and financial eligibility criteria of an existing Medicaid category.

• Applicants must provide documentation of qualified alien status for each person for whom Medicaid is being requested.

• If an alien has a sponsor, the sponsor's income and resources may be deemed available to the alien when determining eligibility. (Re. MS 6760.)

Individuals shown below, who entered the U.S. on or after August 22, 1996, are barred from receiving Medicaid except emergency services for five years. The five-year period

begins on the date the individual entered the U.S. with one of the following statuses:

• Aliens lawfully admitted for permanent residency who do not have (or cannot be credited with) 40 qualifying quarters of coverage as defined under Title II of the Social Security Act and do not have sufficient earnings through noncovered employment. Noncovered employment is work that does not require payment into Social Security because the work is covered by a retirement plan that ends the requirement to pay into Social Security. (Re. [MS 6740] - 6741.)

• Aliens paroled into the U.S. under section 212(d)(5) of the Immigration and Nationality Act (INA) for a period of at least one year.

• Aliens granted conditional entry under section 230(a)(7) of the INA as in effect before April 1, 1980.

• Battered aliens under 8 USC 1641(c). For the alien and children to emigrate or remain in the United States, the alien's spouse must file a petition for lawful permanent residence status via INS Form I-130, Petition for Alien Relative. Unless the spouse files this petition, the alien and children have no lawful immigrant status and face being deported. Since the 1994 enactment of the Violence Against Women Act, a battered alien may self-petition for lawful permanent residency via INS Form I-360, Petition for Amerasian, Widow(er) or Special Immigrant, without the cooperation or knowledge of the abuser.

Note: The five-year bar does not apply to aliens in these categories who entered the U.S. before August 22, 1996.

Aliens with the following statuses are potentially eligible for Medicaid from the date the status is obtained:

• Refugees admitted under section 207 of the Immigration and Nationality Act (INA).

• Aliens granted asylum under section 208 of the INA.

• Aliens whose deportation or removal is withheld under section 243(h) or section 241(b)(3) of the INA.

• Cuban or Haitian entrants under section 501(e) of the Refugee Education Assistance Act of 1980.

• Amerasian immigrants.

• Canadian born American Indians who have treaty rights to cross the U.S. borders with Canada and Mexico.

• Aliens lawfully admitted for permanent residence who have, or can be credited with, 40 qualifying quarters of coverage as defined under Title II of the Social Security Act, or have sufficient earnings through noncovered employment. (Re. [MS 6740] - 6741.)

• Aliens lawfully living in the United States on 8/22/96 who were receiving AABD Medicaid at that time may continue to receive Medicaid benefits. This applies only to AABD categories.

• Aliens lawfully living in the United States on 8/22/96 who subsequently become blind or disabled may receive Medicaid benefits in the future.

• Aliens lawfully admitted for permanent residence who are veterans honorably discharged for reasons other than alienage, and their spouses, surviving unremarried spouses, and unmarried dependent children. This includes alien spouses, surviving unremarried spouses, and unmarried dependent children of veterans who are U.S. citizens or deceased veterans.

• Aliens lawfully admitted for permanent residence who are active-duty personnel of the United States Armed Forces and their spouses, surviving unremarried spouses, and unmarried dependent children. This includes alien spouses, surviving unremarried spouses, and unmarried dependent children of active duty personnel who are U.S. citizens or deceased active duty personnel. Active duty excludes temporary full-time duty for training purposes performed by members of the National Guard or Reserves.

When an alien's eligibility depends on meeting the 40-quarter requirement, the number of quarters with which the individual can be credited must be determined. Individuals can get up to four qualifying quarters of credit each calendar year based on their own earnings. Individuals may also be credited with additional quarters in a calendar year based on the earnings of a parent or spouse.

The chart on Appendix S shows the amounts required to earn one credit beginning with the year 1978. The quarter of coverage amount increases each year with the SSA cost of living increase.

To calculate the number of quarters available for one year, divide the individual's total earnings for the year by the amount needed to get one credit. Amounts remaining that equal less than the amount required for one quarter will not be used. For regular earnings, use the gross amount of earnings. For self-employment, use the amount after allowable self-employment expenses have been deducted.

Note: Beginning with January 1, 1997, do not count the income from any quarters in which an alien received any type of federal means-tested public assistance during the quarter. Means-tested public assistance includes TEA, SSI, Medicaid, and Food Stamps. Emergency Medicaid assistance for aliens is excluded from means-tested public assistance. If means-tested assistance was received, check the alien status in the other program to see if alien status was met for Medicaid eligibility.

Aliens can count their spouse's quarters earned during the marriage in addition to their own quarters to meet the 40-quarter requirement. For example, if each spouse had 20 quarters, the quarters would be added together and both spouses would be credited with having 40 quarters.

Count the spouse's quarters earned during the marriage when the spouse is either a citizen or an alien and any of the following conditions apply:

• The couple is currently married.
• A spouse is deceased and the surviving spouse has not remarried.
• The couple is separated but not divorced

Aliens can also count the quarters earned by a parent in addition to their own quarters to meet the 40-quarter requirement. In this instance, parent means the natural or adoptive parent or the stepparent. Count the parent's quarters when the parent is either a citizen or an alien and the quarters were earned before the child turned 18, including quarters earned before the child was born. Death of the stepparent does not end the relationship. However, if the parent and stepparent are divorced the stepparent's quarters may not be counted.

Quarters earned by a child may not be counted toward the eligibility of a parent.

The individual is responsible for providing verification of qualifying quarters. Acceptable documents for verifying qualifying quarters include:

• Pay stubs
• Employer statements
• Income tax forms
• SSA statements (SSA can verify quarters beginning with the year 1930.)

Public Law104-193 states that aliens who are certified as victims of trafficking by the Department of Health and Human Services' Office of Refugee Resettlement (ORR) are eligible aliens for Medicaid purposes. Eligibility for victims of trafficking is determined in the same manner as Medicaid for refugees.

Trafficking is defined as all acts involved in the movement of human beings, usually women and children, from one country to another or within national borders for sexual exploitation or forced labor.

Certification for victims of trafficking is valid for one eight-month period from the date of the initial certification date. The individual's entry date, which is found on the ORR certification letter, is the certification date. A recertification letter must be issued by the ORR for the individual to receive Medicaid beyond the initial eight-month period.

Follow the usual procedures for determining eligibility for refugees except:

• Accept the original ORR certification letter for adults or letter for children under 18 in place of INS documentation.

• Contact the trafficking verification line at (202) 401-5510 to confirm the validity of certification letters and to notify the ORR of the assistance for which the individual has applied.

Note: Do not contact SAVE concerning victims of trafficking.

If the worker suspects that an applicant may be a victim of trafficking but does not have the required certification letter, assist the individual in contacting ORR at (202) 401-5510, for possible certification.

PRWORA, as amended by the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), P. L. 104-208, and the Balanced Budget Act of 1997 (BBA), P. L. 105-33, created new rules for deeming income and resources from an alien sponsor to Lawfully Admitted Permanent Residents (LAPRs).

Aliens who seek admission to the U.S. as LAPRs must establish that they will not become a public charge (Re: [MS 6715]). Many aliens enter the country by having a sponsor who pledges to support them to establish that they will not become a public charge.

A sponsor is a person who signs an Affidavit of Support agreeing to support an alien as a condition of the alien's admission for permanent residence in the U.S. An alien may have more than one sponsor. There are two versions of the Affidavit of Support:

• Affidavit of Support, form I-134 (Now unenforceable.)
• Affidavit of Support, form I-864 (Effective December 19, 1997.)

Counting the sponsor's income and resources for the sponsored alien is called deeming. Deeming will not apply when the sponsor is:

• An organization such as a church or service club.
• An employer who does not sign an Affidavit of Support.
• The alien's eligible or ineligible spouse or parent whose income is otherwise considered in determining the alien's Medicaid eligibility.

A sponsored alien and the alien's spouse, if there is one, are responsible for providing information and documentation about the alien's sponsor and the sponsor's spouse. If the alien appears to be eligible for benefits but does not have the Affidavit of Support or does not know if there is a sponsor, instruct the alien to contact the INS to obtain a copy of the Affidavit of Support. If the applicant requires assistance, the caseworker may request information from INS by submitting Forms G-845 and G-845 Supplement.

The INS will certify whether an alien has a sponsor and if so, what kind of affidavit the sponsor signed. Do not deem income or resources from a sponsor that has signed the old version, I-134, Affidavit of Support, or I-361, Affidavit of Financial Support and Intent to Petition for Legal Custody, as these affidavits are not considered enforceable.

For individuals applying for Medicaid having an I-864, Affidavit of Support, deeming instructions are shown below:

• Count all income of the sponsor and sponsor's spouse living in the same household as if they were income and resources of the alien.

• Do not allow deductions from the sponsor's income or resources.

• Count the sponsor's income as the alien's unearned income and use it to determine the alien's eligibility.

• Do not count the sponsor's income when determining eligibility for the alien's eligible children.

• Do not include the sponsor in the alien's household size.

Deeming continues until one of the following conditions is met:

• The sponsored immigrant accrues 40 quarters of work credit.
• The sponsored immigrant becomes a U.S. citizen.
• The sponsored immigrant leaves the U.S. permanently.
• The sponsored immigrant or the sponsor dies.

Deeming from the alien's sponsor can be suspended for some aliens. The following aliens are not subject to deeming:

• Aliens who do not have sponsors.

• Aliens who have been battered or subject to extreme cruelty in the United States, and their children or parents who have been battered or subject to extreme cruelty. This exception applies for 12 months from the date of determination that the alien has been battered. (Re: [MS 6765].)

• Aliens who are indigent. (Re: [MS 6767].)

• Aliens who can be credited with 40 qualifying quarters or attain citizenship.

• Aliens qualifying for Emergency Medicaid services only. (Re: [MS 6780].)

To qualify for an exception to sponsor deeming due to battery, the battered person may be the alien, or the child or parent of the alien. The abuse may be perpetrated by a U.S. citizen or lawful permanent resident spouse, parent, or their family members living in the same household in the U.S.

The battered alien may be eligible for Medicaid if he/she entered the U.S. before August 22, 1996. If the date of entry is on or after August 22, 1996, the battered alien, spouse or child is subject to the five-year bar, except for emergency medical treatment.

Due to the abusive relationship, battered aliens may not have access to the needed INS documents. Applicants without documentation should be referred to the INS Forms Request Line, 1-800-870-3676.

An alien with a sponsor who signed form I-864, Affidavit of Support, may be determined to be indigent and exempt from deeming policies if the alien is unable to obtain food and shelter.

If the alien lives with the sponsor, it will be assumed that the sponsor is providing food and shelter and the indigence exception will not be granted, and deeming will apply.

If the alien is living apart from the sponsor, consider the alien unable to obtain food and shelter if:

• The income the alien receives is less than the income limit for the category of Medicaid for which the individual would be eligible.

• The resources available to the alien are under the resource limit for the Medicaid category for which the alien would be eligible.

When the individual provides documentation of alien status, check the Alien Documentation Chart that follows. The chart shows the types of documentation that can be used to verify alien status, and additional verification that certain aliens must provide to verify that they are eligible for Medicaid (e.g., the date they were admitted to the U.S., or the date a particular alien status was granted or adjusted).

*In 1998, the INS changed the name of Form I-551 from "Alien Registration Receipt Card" to "Permanent Resident Card" because the new name more appropriately identifies the individual as having permanent resident status.

If the documentation provided does not contain all the information needed to establish the alien's eligibility, additional verification can be obtained from the INS by contacting them in writing, using form G-845, or by contacting SAVE by phone.

If the documentation provided appears questionable, contact INS in writing using form G-845 to attempt verification of the document, rather than using SAVE.

Medicaid benefits are available to pay for the cost of emergency services for aliens who do not meet the Medicaid citizenship or alien status requirements or Social Security Number requirements. However, they must meet the financial and categorical eligibility requirements and state residency requirements for the category in which they apply. Individuals eligible for emergency medical coverage only include:

• Nonqualified aliens living in the U.S.
• Qualified aliens living in the U.S. for less than 5 years.

To be eligible for emergency Medicaid, the applicant must have, or must have had within the last 3 months, an emergency medical condition. Labor and delivery is considered an emergency medical condition.

Emergency medical condition is defined as a medical condition, including labor and delivery, manifesting itself by acute symptoms of such severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in at least one of the following:

• Placing the patient's health in serious jeopardy
• Serious impairment of bodily function
• Serious dysfunction of any bodily part or organ

To qualify as an emergency, the medical condition must be acute. It must have a sudden onset, a sharp rise and last a short time. If the individual's condition is chronic (ongoing), such as cancer, AIDS, end-stage renal disease, etc., it is not considered acute and does not meet the definition of an emergency. If the chronic condition worsens, it is still not acute and does not qualify for emergency services. Federal policy specifically identifies care and services related to an organ transplant procedure as not qualifying under emergency services.

Before eligibility can be determined, the existence of an emergency medical condition must be verified by a physician's statement that the alien met the conditions shown above. Having a physician's statement that the individual will die without medical treatment does not, in and of itself, constitute an emergency. The eligibility determination must include a determination of whether the condition is acute or chronic. Verification that medical expenses were incurred for treatment of the condition must also be presented.

Payment for emergency services is limited to the day treatment was initiated and the following period of time in which the necessity for emergency services existed. (E.g. the date of admission through the date of discharge from the hospital.) The date the alien first sought treatment is considered the first day of the emergency, regardless of the length of time the condition exists. The period of eligibility will be a fixed retroactive period, with the Medicaid begin and end dates entered in the system.

Emergency services are defined as services provided in a hospital, clinic, office or other facility equipped to furnish the required care after the onset of an emergency medical condition. Labor and delivery services are covered, including normal deliveries.

When determining eligibility for emergency services for an adult, the income of a non-qualified alien spouse will be deemed to the applicant, but his or her needs will not be included in the needs standard.  A citizen or qualified alien spouse's income must be counted in full, with his or her needs included.  The income and needs of non-qualified alien children will be disregarded.  A citizen or qualified alien child's income and needs may be included if needed.

The INS issues non-immigrant visas to people who indicate that they are seeking entry for a temporary purpose. These non-immigrants do not meet the residency requirements and are not eligible for emergency services. The following groups of people are ineligible:

• Foreign government representatives on official business and their families and servants.
• Visitors for business or pleasure, including exchange visitors.
• Aliens traveling through the U.S.
• Crew members on shore leave.
• Treaty traders and investors and their families.
• Foreign students and their families who are here as dependents and are not otherwise eligible.
• International organization representatives and personnel and their families and servants.
• Temporary workers including agricultural contract workers.
• Members of foreign press, radio, film or other information media and their families.