Implementation Guides

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CS18 - Non-Financial – Citizenship
Statute: 2105(c)(9) of the SSA 2107(e)(1)(J); 211 and 214 of CHIPRA 2009; 8 U.S.C. sections
1612, 1613 and 1641
Regulations: 42 CFR 457.320(b)(6), (c) and (d) and 457.380 (b)

INTRODUCTION

To be completed by states with separate child health assistance programs.
In state plan page CS18, the state provides information regarding its citizenship rules and
provision of Medicaid to citizens and nationals of the United States and to certain non-citizens.

BACKGROUND

State CHIP programs are required to provide CHIP coverage to otherwise eligible residents of
the United States who are citizens or nationals of the United States or qualified non-citizens as
described in section 431 of the Personal Responsibility and Work Opportunity Reconciliation
Act of 1996 (8 U. S. C. section 1641).
Effective January 1, 2010, section 2105(c) of the Act was amended to apply to separate CHIP
programs, the same requirements as in Medicaid with respect to required verification of
citizenship or nationality, for individuals who have declared themselves to be U. S. citizens and
who are required to verify their citizenship status. In a January 22, 2013 notice of proposed
rulemaking (78 FR 4594), CMS proposed revisions to citizenship regulations. The revised 42
CFR 457.320 adds a requirement that citizenship and immigration verification must be done in
accordance with revised 457.380. Revised 457.380 also requires states to verify citizenship or
immigration status in accordance with Medicaid rules at 435.956(a) and to provide individuals
with a reasonable opportunity period to verify their citizenship or immigration status in
accordance with Medicaid rules at 435.956(g). The reasonable opportunity period must be at
least 90 days from when notification of the reasonable opportunity period is received by the
individual. States also have the option to extend the reasonable opportunity period beyond 90
days if the individual is making a good faith effort to resolve any inconsistencies or obtain any
necessary documentation.
States also have the option to cover non-citizen pregnant women and children who are lawfully
residing in the United States during the 5 year waiting period. This option was added by section
214 of CHIPRA (as amended by the ACA) which added section 2107(e)(1)(J) of the SSA and
gives states the option to provide CHIP to lawfully residing pregnant women (including the 60day postpartum period) and/or children up to age 19. To meet the criteria of lawfully residing
and to qualify under this option, an individual must be both lawfully present in the U. S. and a
resident of the state. A listing of individuals who may be considered lawfully present may be
found in 435.4.

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CS18 - Non-Financial – Citizenship
States may not select the option to cover lawfully residing non-citizen pregnant women and
children under CHIP if they do not also cover them under their state’s Medicaid program.
Additionally states may not elect to cover pregnant women under this option without also
covering children.

TECHNICAL GUIDANCE
PREREQUISITES:
For states electing to cover lawfully residing children for the first time:
State plan page CS7 (Targeted Low-Income Children) must have been submitted prior to or
concurrently with CS18.
Medicaid state plan page S89 (Citizenship), including election of lawfully present children,
must have been submitted prior to or on the same day as CS18.
Review Criteria
If either state plan pages CS7 (targeted low-income children) and/or S89 (Citizenship) are not
approved, state plan page CS18 cannot be approved.
For states electing to cover lawfully residing pregnant women for the first time:
State plan page CS8 (Targeted Low-Income Pregnant Women) must have been submitted
prior to or concurrently with CS18.
Medicaid state plan page S89 (Citizenship), including election of lawfully present pregnant
women, must have been submitted prior to or on the same day as CS18.
Review Criteria
If either state plan pages CS8 (targeted low-income pregnant women) and/or S89 (Citizenship)
are not approved, state plan page CS18 cannot be approved.
This state plan page is broken down into the following sections:
•
•

Assurance
Policy Statement
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CS18 - Non-Financial – Citizenship
•
•

Reasonable Opportunity Period
Lawfully Residing Options

Assurance
State plan page CS18 begins with the state providing assurance that it provides CHIP to citizens
and nationals of the United States and certain non-citizens, including the time period during
which they are provided with reasonable opportunity to submit verification of their citizenship,
national or immigration status.
The state provides this affirmative assurance by checking the assurance box at the top of state
plan page CS18.
Review Criteria
The state must check the assurance box or this state plan page cannot be approved.
Policy Statement
This section begins with a statement that supports the assurance above, followed by a listing of
the three citizen/non-citizen categories which must be provided CHIP coverage.
Reasonable Opportunity Period
This section begins with a statement that “The reasonable opportunity period begins on and
extends 90 days from the date the notice of reasonable opportunity is received by the individual”.
This statement is followed by two Yes/No questions:
• The agency provides for an extension of the reasonable opportunity period if the
individual is making a good faith effort to resolve any inconsistencies or obtain any
necessary documentation, or the agency needs more time to complete the verification
process.
• The agency begins to furnish benefits to otherwise eligible individuals during the
reasonable opportunity period on a date earlier than the date the notice is received by the
individual.
Review Criteria
The state must select either yes or no to each of the two questions or this state plan page
cannot be approved.

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CS18 - Non-Financial – Citizenship
If the answer to the second question is yes, the state then indicates the date that benefits
are furnished by selecting one of the three options displayed. If “Other is selected, the
state then describes the date used in the space provided.
Review Criteria
The state must enter a description or this state plan page cannot be approved. The
description should be sufficiently clear, detailed and complete to permit the reviewer to
determine that the state’s election meets applicable federal statutory, regulatory and
policy requirements.
Lawfully Residing Options
This section consists of two questions. The first question asks if the state elects the option to
provide CHIP coverage to otherwise eligible children, lawfully residing in the United States.
Review Criteria
The state must select either yes or no or this state plan page cannot be approved.
If the response to the question is yes, the definition for “otherwise eligible children” is displayed.
The state then provides assurance that lawfully residing children are also covered under the
state's Medicaid program. The state provides this affirmative assurance by checking the box next
to the assurance statement.
Review Criteria
The state must check the assurance box or this state plan page cannot be approved.
The Medicaid state plan must be checked to verify that lawfully residing children are also
covered under the state's Medicaid program.
The second question asks if the state elects the option to provide CHIP coverage to otherwise
eligible pregnant women, lawfully residing in the United States.
Review Criteria
The state must select either yes or no or this state plan page cannot be approved.
If the answer is yes, the definition for “otherwise eligible pregnant women” is displayed. The
state then provides assurance that lawfully residing pregnant women are also covered under the
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CS18 - Non-Financial – Citizenship
state's Medicaid program. The state provides this affirmative assurance by checking the box next
to the assurance statement.
Review Criteria
The state must check the assurance box or this state plan page cannot be approved.
The Medicaid state plan must be checked to verify that lawfully residing pregnant women are
also covered under the state's Medicaid program and the CHIP plan must also be checked to
verify that lawfully residing children are also covered under CHIP. If lawfully residing
pregnant women are not covered under the state's Medicaid program and/or lawfully residing
children are not covered under CHIP, this state plan page cannot be approved.

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