54.08 Documentation of immigration status for qualified non-citizens

If verification of immigration status cannot be obtained through the process described in § 54.04, a non-citizen individual seeking health benefits as a qualified non-citizen must provide United States Citizenship and Immigration Services (USCIS) documents to establish immigration status, as specified below: Lawful Permanent Resident USCIS Form I-551; or For recent arrivals, a temporary I-551 stamp on a foreign passport or on Form I-94. Note: Forms I-151, AR-3 and AR-3A have been replaced by USCIS. If presented as evidence of status, contact USCIS to verify status by filing a G-845 with a copy of the old form. Refer the individual to USCIS to apply for a replacement card. (b) Refugee The following documents may be used to document refugee status: (i) USCIS Form I-94 endorsed to show entry as refugee under § 207 of INA and date of entry to the United States; (ii) USCIS Form I-688B annotated “274a.12(a)(3)”; (iii) Form I-766 annotated ”A3”; or (iv) Form I-571. Refugees usually change to Lawful Permanent Resident status after 12 months in the United States, but for the purposes of health-benefits eligibility are still considered refugees. They are identified by Form I- 551 with codes RE-6, RE-7, RE-8, or RE-9. (c) Asylee USCIS Form I-94 annotated with stamp showing grant of asylum under § 208 of the INA; 32 42 CFR § 435.407(f). Eligibility-and-Enrollment Procedures Part 7 – Page 13 (Sec.54.00, Sub.54.09) A grant letter from the Asylum Office of the USCIS; Form I-688B annotated “274a.12(a)(5)”; Form I-766 annotated “A5”; or An order of the Immigration Judge granting asylum. If a court order is presented, file a G-845 with the local USS district office attaching a copy of the document to verify that the order was not overturned on appeal. (d) Cuban or Haitian entrant An I-94 Arrival/departure card with a stamp showing parole into the United States on or after April 21, 1980. I-94 may refer to § 212(d)(5). I-94 may refer to humanitarian or public interest parole. I-94 may be expired; An I-94 Arrival/departure card with a stamp showing parole at any time as a “Cuban/Haitian Entrant (Status Pending).” I-94 may refer to § 212(d)(5). I-94 may be expired; CH6 adjustment code on the I-551. Even after a Cuban/Haitian Entrant (Status Pending) becomes a permanent resident, they technically retain the status Cuban/Haitian Entrant (Status Pending). I-551 may be expired; or A Cuban or Haitian passport with a § 212(d)(5) stamp dated after October 10, 1980. Passport may be expired. (e) Non-citizen granted parole for at least one year by the USCIS. USCIS Form I-94 endorsed to show grant of parole under § 212(d)(5) of the INA and a date showing granting of parole for at least one year. (f) Non-citizen granted conditional entry under the immigration law in effect before April 1, 1980 USCIS Form I-94 with stamp showing admission under § 203(a)(7) of the INA, refugee-conditional entry; Form I-688B annotated “274a.12 (a)(3)”; or Form I-766 annotated “A-3.” (g) Non-citizen who has had deportation withheld under § 243(h) of the INA Order of an Immigration Judge showing deportation withheld under § 243(h) of the INA and date of the grant; USCIS Form I-688B annotated “247a.12(a)(10)”; or Form I-766 annotated “A10.” 54.09 Documentation of entry date for determining the Medicaid five-year bar for qualified non- Eligibility-and-Enrollment Procedures Part 7 – Page 14 (Sec.54.00, Sub.54.09) citizens (01/15/2017, GCR 16-100) The following are the documents that may be used to determine the Medicaid five-year bar for qualified non- citizens (§ 17.03): Form I-94. The date of admission should be found on the refugee stamp. If missing, AHS will contact USCIS to verify the date of admission by filing a G-845 with a copy of the document; If an individual presents Forms I-688B or I-766 (Employment Authorization Documents), and I-57 (refugee travel document), AHS will ask the individual to present Form I-94. If not available, AHS will contact USCIS by filing a G-845 with a copy of the document presented; or Grant letters or court orders. AHS will derive the date status is granted from the date of the letter or court order. If missing, AHS will contact USCIS to verify date of grant by filing a G-845 with a copy of the document. (b) If an individual presents a receipt indicating that they have applied to USCIS for a replacement document for one of the documents identified above, AHS will contact the USCIS to verify status by filing a G-845 with the local USCIS district office with a copy of the receipt. AHS will contact the USCIS any time there is a reason to question the authenticity of a document presented or the information on the document is insufficient to determine whether non-citizen status requirements are met. 54.10 [Reserved] (01/01/2026, GCR 25-055) 54.11 Visitors, tourists, and some workers and diplomats ineligible for Medicaid (01/01/2026, GCR 25-055) For purposes of Medicaid eligibility, some non-citizens may be lawfully admitted to the United States but only for a temporary or specified period of time as non-immigrants33 (e.g., visitors, tourists, and some workers and diplomats) and are generally ineligible for Medicaid unless they are eligible pursuant to § 17.03(c)(6). These non-immigrants would have the following types of documentation: Form I-94 Arrival-Departure Record; (b) Form I-185 Canadian Border Crossing Card; (c) Form I-186 Mexican Border Crossing Card; (d) Form SW-434 Mexican Border Visitor’s Permit; or (e) Form I-95A Crewman’s Landing Permit. 33 8 USC § 1101(a)(15). Eligibility-and-Enrollment Procedures Part 7 – Page 15 (Sec.55.00, Sub.55.01) Attestation and verification of other nonfinancial information34 (01/01/2026, GCR 25- 055)