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Chapter: 1400 Technical Requirements Program: MSSI, SFP 29 3. Verification of eligibility under the Child Citizenship Act of 2000, including the U.S. citizenship of the parent, 4. A U.S. birth certificate (originally issued prior to age five) (except for voided Puerto Rican birth certificates after September 30, 2010), 5. A final adoption decree, or if the adoption is pending and no birth certificate can be issued, a statement from the state adoption agency (U.S. born children), 6. A Report of Birth Abroad of a U.S. citizen (forms FS-240, FS-545 or DS1350), 7. A U.S. Citizen I.D. card (DHS form I-197 or I-179), 8. A Northern Mariana ID card (I-873), 9. An American Indian card (I-872, with “KIC” code), 10. Proof of civil service employment before 6/1/76, or 11. Official military record of service (ex.DD-214).

If none of the above documents exist or can be located, the following documents can be used to verify U.S. citizenship if they show a U.S. place of birth and are dated five years prior to the Medicaid application (unless for a child under age five):

1. Extract of hospital birth record on hospital letterhead (not a souvenir birth certificate), 2. Life or health insurance record with a U.S. place of birth, 3. Early school record, or 4. Religious record (ex baptism) within three months of birth.

If none of the above documents exist or can be located, the following documents can be used to verify U.S. citizenship if they show a U.S. place of birth and are dated five years prior to the Medicaid application (unless for a child under age five):

1. Federal census records from 1900-1950 showing the age and place of birth (the five year rule does not apply), 2. Tribal census records, 3. An amended birth certificate, after age five, 4. A signed statement from the doctor or midwife who was present at the birth, 5. Nursing home institution records that contain biographical information, 6. Medical records with biographical information, 7. Listed on the roll of Alaskan natives, or 8. A written statement signed under penalty of perjury by at least two people who have personal knowledge of the event(s) – (One cannot be related.). They must also prove their own citizenship and identity. A separate statement by the applicant/recipient/representative, signed under penalty of perjury, must also be completed stating why the documentation could not be obtained. 1440.0104 Noncitizens (MSSI, SFP) Noncitizens may qualify for Medicaid based on their status granted by U.S. Citizenship and Immigration Services (USCIS). The following sections discuss different types of noncitizens and their eligibility.

A North American Indian born in Canada, who is residing in the U.S., is eligible for Medicaid benefits, based on the factor of noncitizen status, if they are subject to section 289 of the Immigration and Nationality Act or a member of an Indian tribe as defined in section 4(e) of the Indian Self-Determination and Education Assistance Act.

Proof of this status includes:

1. I-551 with code S-13, 2. unexpired temporary I-551 stamp in a Canadian passport, 3. I-94 with code S-13, or