Page 12

Page 12 – State Health Officials

(9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

___ Elected for pregnant women. ___ Elected for children under age _____.

g. _____ The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA section 214 option, it has verified, at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

TN No: Approval Date Effective Date ____________ Supersedes TN No.