MMIS Changes to Support MinnesotaCare Citizenship and Immigration Status Verification Requirements

#10-21-13 Bulletin August 27, 2010 Minnesota Department of Human Services -- P.O. Box 64941 -- St. Paul, MN 55164-0941 OF INTEREST TO County Directors MinnesotaCare Operations Managers, Supervisors and Staff Financial Assistance Supervisors and Staff Social Services Supervisors and Staff Mille Lacs Tribal TANF Case Managers ACTION/DUE DATE Please implement starting on August 31, 2010 EXPIRATION DATE August 27, 2012 MMIS Changes to Support MinnesotaCare Citizenship and Immigration Status Verification Requirements TOPIC MinnesotaCare citizenship and immigration status verification requirements. PURPOSE This bulletin introduces changes to the Medicaid Management Information System (MMIS) to automate MinnesotaCare citizenship and immigration status verification tracking and notices. CONTACT Counties, tribal agencies and MinnesotaCare Operations should submit policy questions to HealthQuest. All others direct questions to: Health Care Eligibility and Access (HCEA) Division P.O. Box 64989 540 Cedar Street St. Paul, MN 55164-0989 SIGNED BILLI JO ZIELINSKI Assistant Commissioner Health Care Administration

Page 2 I. Background and Introduction This bulletin introduces new MMIS functionality to automate the citizenship and immigration status verification process. People who state they are U.S. citizens must cooperate with requirements to verify their citizenship if they are applying for or enrolled in MinnesotaCare for families with children. People who report they are noncitizens must cooperate with requirements to verify their immigration status if they are applying for or enrolled in MinnesotaCare for families with children or adults without children. Prior to August 31, 2010, workers manually requested verification of citizenship or immigration status for MinnesotaCare and tracked responses. MMIS will include the following new functionality beginning August 31, 2010: The U.S. Citizenship and Identity Verification (RCIT) screen is renamed U.S. Citizenship and Immigration Verification (RCIT) and will include immigration status verification information. The MMIS RCIT screen will trigger notices to request verification of citizenship or immigration status for MinnesotaCare clients who are pending awaiting payment (P41) or active ongoing (A00) and will track for return of verifications. MMIS will automatically close MinnesotaCare eligibility for enrollees who fail to provide required proof of citizenship or immigration status and will prevent future approval for individuals until they cooperate. MMIS will issue two new ereports to identify clients who: (1) are denied or cancelled for failure to provide proof of citizenship or immigration status, and (2) who have been cooperating with citizenship or immigration status documentation requirements for more than 180 days. This bulletin also provides information about a change to MinnesotaCare eligibility policy. Beginning with applications processed on and after August 31, 2010, the All or Nothing Rule will no longer apply to verification of citizenship and immigration status. All other information in this bulletin pertains only to process and systems changes to support workers in requesting and collecting citizenship and immigration status verifications. Note: For purposes of this bulletin, the term citizenship means both citizenship and identity. Citizenship verification requirements include separate proof of identity when clients submit lower levels of citizenship documentation (that is, if a birth certificate is submitted, identity documentation is also required).

Page 3 This bulletin provides the following policy and systems instructions: II. Action required A. Changes to the All or Nothing Rule. B. Verifying Citizenship or Immigration Status beginning August 31, 2010. C. MMIS Systems Instructions. D. Reports. III. Case Examples. IV. Attachments. A. New Codes for TYPE Field on RCIT. B. Minnesota Health Care Programs 1st Request for Proof of Citizenship and Identity. C. MinnesotaCare 1 st Request for Proof of Immigration Status. D. Minnesota Health Care Programs 2nd Request for Proof of Citizenship and Identity. E. MinnesotaCare 2nd Request for Proof of Immigration Status. V. Legal Reference. VI. ADA Advisory. II. Action Required A. Changes to the All or Nothing Rule Effective with applications processed on or after August 31, 2010, do not apply the All or Nothing Rule to enrollees who fail to submit proof of citizenship or immigration status. Citizenship and immigration status are individual-based eligibility tests and do not affect eligibility for other household members. Close, deny or pend eligibility only for the individual who fails to provide proof and is not cooperating with efforts to verify citizenship or immigration status. B. Verifying Citizenship or Immigration Status beginning August 31, 2010 Continue to request verification of citizenship or immigration status from clients during the application process, along with other information or verifications needed to determine eligibility. Enter case notes with detailed information about citizenship and immigration documentation or exemption from documentation. The Minnesota Health Care Programs (MHCP) Worker Checklist Proof of U.S. Citizenship and Identity (DHS-4842) is no longer required. RCIT coding and case notes meet documentation requirements for MinnesotaCare cases. Send the MHCP Request for Information (DHS-3271) at initial application processing if other information or verifications are required. Request all necessary

Page 4 verifications, including proof of citizenship or immigration status. Enclose the MHCP Citizenship and Identity Proofs (DHS-6231) if citizenship documentation is needed. Approve MinnesotaCare if the client submits all requested information and verifications except proof of citizenship or immigration status, and meets all other eligibility requirements. The MMIS automated citizenship and immigration request process will begin when eligibility is approved even if proof of citizenship or immigration status has not been received. MMIS will send a notice requesting verification when eligibility is approved pending awaiting payment or active ongoing (P41 or A00) for one or more clients who need to submit proof of citizenship or immigration status. MMIS will issue the first notice the day eligibility is approved. MMIS will automatically send a second notice 60 days later if proof has not been received. MMIS will close or deny MinnesotaCare eligibility with 10-day notice if proof is not returned within 30 days of the second request. C. MMIS System Instructions 1. U.S. Citizenship / Immigration Verification (RCIT) Screen Entry It is important to code the RCIT screen correctly in order for MMIS to accurately track and send requests for citizenship or immigration documentation. The RCIT screen is divided into two sections: U.S. Citizenship/Immigration Verification and Identity Verification (divided by a line in the middle of the screen). Certain fields on the RCIT screen must be completed in order to take action on a case. If these mandatory fields are not complete, edits will prevent saving case changes and eligibility. Follow these instructions to code RCIT: a. U.S. CITIZENSHIP/IMMIGRATION VERIFICATION field (worker entered): This is a mandatory field. Enter the appropriate number code 1-6: 1 - CITIZENSHIP DOCUMENTS RECEIVED Use this code for individuals who are citizens and have provided complete citizenship documentation. Complete citizenship documentation includes verification of identity if Level 2-4 documentation of citizenship is submitted. Do not code this field 1 unless complete documentation of citizenship and identity is received.

Page 5 2 - CITIZENSHIP DOCUMENTS NEEDED Use this code for individuals who are citizens and have not provided citizenship documentation. This code will trigger the automated first and second request notices. 3 - IMMIGRATION DOCUMENTS RECEIVED Use this code for noncitizens that have provided immigration documentation. 4 - IMMIGRATION DOCUMENTS NEEDED Use this code for noncitizens that have not provided immigration documentation. This code will trigger the automated first and second request notices. 5 - COOPERATING Use this code for individuals who are cooperating with the citizenship or immigration request process. 6 - EXEMPT Use this code for individuals who are exempt from the citizenship or immigration request process. b. TYPE field (worker entered): This is a mandatory field if the U.S. CITIZENSHIP/IMMIGRATION VERIFICATION field is coded 1 - CITIZENSHIP DOCUMENTS RECEIVED or 3 - IMMIGRATION DOCUMENTS RECEIVED. Enter the code that corresponds with verification provided (PF12 for a list of codes or see Attachment A). Note: Use SSA Data Match results from the MAXIS STAT/MEMI panel to verify citizenship, if available. An SSA Data Match is considered a Level 1 citizenship document. More information about the SSA Data Match is available in POLI / TEMP manual section TE02.08.166 CITIZENSHIP & IMMIG VER. FOR MA APPL. c. DATE REQUESTED field (system entered): This field is populated when RCIT is coded and the case is saved. Once populated, this field is locked and cannot be changed. d. SECOND REQUEST field (system entered): This field is updated systematically by MMIS approximately 60 days after the first request date. This field triggers MMIS to send the second request. Once populated, this

Page 6 field is locked and cannot be changed. e. DATE RECEIVED field (worker entered): Enter the date citizenship or immigration status documentation is received. f. LOCATION field (worker entered): Enter the service location code where the case is being processed. g. IDENTITY VERIFICATION RECEIVED (Y/N) field (worker entered): This is a mandatory field that must be coded for all clients, including noncitizens. Enter Y if: the client submits Level 1 documentation of citizenship. Level 1 documentation of U.S. citizenship verifies both identity and citizenship (for example, a passport). the client submits Level 2-4 documentation of citizenship and submitted verification of identity (for example, a birth certificate and driver s license). Enter N if: the client is a noncitizen. Proof of identity is not required as part of the immigration documentation requirement. the client does not submit complete citizenship documentation, including proof of identity. MMIS will not send requests for proof of citizenship or immigration status to the client if this field is coded N. h. TYPE (worker entered): This is a mandatory field if the IDENTITY VERIFICATION RECEIVED (Y/N) field is coded Y. Enter the code that corresponds with the identity verification provided (PF12 for a list of codes). Do not fill out the remaining identity fields. Note: If the IDENTITY VERIFICATION (Y/N) field is coded with a Y and a type is entered in the TYPE field, then the DATE RECEIVED field becomes a mandatory field. See Health Care Programs Manual (HCPM) Section 11.05.05 - Acceptable Documentation of U.S. Citizenship and Identity for more information about the citizenship documentation hierarchy.

Page 7 2. Case Updates Prior to Receipt of Citizenship or Immigration Documentation Attempts to update the case after eligibility approval but before proof of citizenship or immigration status has been received will prompt MMIS to do one of the following: If the DATE REQUESTED field on RCIT is blank: MMIS will send out the corresponding household based request form for all household members lacking citizenship or immigration verification and will populate the DATE REQUESTED field on RCIT with the current date. If the first request for proof of citizenship or immigration status was sent less than 90 days ago: MMIS will track these clients, mail out system generated notices as previously scheduled, and close coverage after 90 days, unless the U.S. CITIZENSHIP /IMMIGRATION VERIFICATION field on RCIT is changed to 5 COOPERATING. If the first request for citizenship or immigration status was sent 90 days ago, or longer: MMIS will produce an inhibiting edit that prevents changes from being saved on the case. Change P41 to the appropriate denial code (D64 or D82) on RELG in order to save results. If the client is A00, close with the appropriate closing code (D64 or D82) for not providing proof of citizenship or immigration status. Refer to the MMIS Walk-thru: CHIPRA System Changes in the MMIS section of the State Information Resource (SIR) for additional information. 3. Denial or Closure for Failure to Submit Proof of Citizenship or Immigration Status MinnesotaCare clients previously closed for failure to submit proof of citizenship or immigration status must submit proof or meet an exception before being approved (P41) for MinnesotaCare. Upon receipt of verifications, remove the 81 CITIZENSHIP VERIFICATION code from RIND, update RCIT according to the documents provided and approve MinnesotaCare. Clients who reapply for MinnesotaCare after being closed for failure to provide proof of citizenship or immigration will have a break in coverage. 4. RCIT Conversion In August 2010, MMIS will convert most cases with existing RCIT data to the

Page 8 new RCIT data field format. The conversion will also delete any RCIT data for clients with major programs JJ, KK and XX, and noncitizens with major program BB. Clients without existing RCIT data will not be converted. MMIS edits will prevent action on cases without RCIT data until updates are made to the RCIT screen for these clients. 5. MMIS Automated Monthly Process for Citizenship and Immigration Documentation Thirteen business days prior to the end of each month, the following will occur: a. MMIS will send a second request notice for citizenship or immigration documentation to clients: with major program FF, JJ, KK, BB or LL who are A00 or P41, who have a 2 or 4 coded for U.S. CITIZENSHIP / IMMIGRATION VERIFICATION field, and who have a date in the DATE REQUESTED field on RCIT that is equal to or greater than 60 days ago. b. MMIS will close or deny clients who have not returned citizenship or immigration documentation within 90 days and who: are major program FF, JJ, KK, BB or LL who are coded as A00 or P41, have a 2 or 4 coded for U.S. CITIZENSHIP / IMMIGRATION VERIFICATION field, and have a date in the SECOND REQUEST field on RCIT that is equal to or greater than 30 days ago. c. MMIS will take the following actions to close or deny clients who have not returned required documentation within 90 days: Clients who are A00 and have not submitted citizenship verification will close with a C82 (CITIZENSHIP VERIF NOT RECEIVED). Those who are P41 and have not submitted citizenship verification will deny with a D82. Clients who are A00 and have not submitted immigration verification will close with a C64 (IMIG DOC STATUS NEEDED). Clients who are P41 and have not submitted immigration verification will deny with a D64. 6. Exception to the MMIS Automated Monthly Process The MMIS automated monthly process will not close, deny, or send request notices for U.S. citizens eligible for major programs JJ or KK if they fail to provide proof of citizenship. These are guardians, foster parents or incarcerated individuals who are eligible for MinnesotaCare but are not eligible for federal funding. For these clients:

Page 9 Code the U.S. CITIZENSHIP / IMMIGRATION VERIFICATION field on RCIT with a 6 (exempt). The TYPE field is not required when the CITIZENSHIP / IMMIGRATION VERIFICATION field has an exempt code. Request documentation by sending the MHCP Request for Information (DHS- 3271) and track for return. 7. New MMIS Notices MMIS will automatically send notices (Attachments B, C, D and E) to request documentation of citizenship or immigration status when RCIT is coded and MinnesotaCare is approved (P41 or A00). Each MinnesotaCare household will receive one notice for all household members who are required to submit documentation. a. The MHCP 1 st Request for Proof of Citizenship and Identity and 1 st Request for Proof of Immigration Status forms are MMIS-generated notices. MMIS sends these notices when a worker: Approves MinnesotaCare (P41 or A00), Codes the RCIT U.S. CITIZENSHIP/IMMIGRATION VERIFICATION field 2 CITIZENSHIP DOCUMENTS NEEDED or 4 IMMIGRATION DOCUMENTS NEEDED, and Saves the results. If the DATE REQUESTED field on RCIT is blank, MMIS will enter the current date and send first request notice that night. b. The MHCP 2 nd Request for Proof of Citizenship and Identity and 2 nd Request for Proof of Immigration Status forms are MMIS-generated notices. MMIS sends these notices out on a monthly basis to clients who received a first request notice 60 or more days ago. 8. New MMIS Edits and Warning Messages The following new edits and warning messages have been programmed in MMIS: a. VERIFICATION HAS BEEN RECEIVED. ENTER DATE RECEIVED This inhibiting edit displays if there is conflicting information on the RCIT screen. For example, if the U.S. CITIZENSHIP / IMMIGRATION VERIFICATION field on RCIT is coded with a 1 Citizenship Documents Received or 3 Immigration Documents Received, but the DATE RECEIVED field has not been completed. b. RCIT MUST BE COMPLETED WITH STATUS/REASON This inhibiting edit displays if a client with major program FF, JJ, KK, BB or LL, is P41 or A00 and does not have anything coded on the RCIT screen.

Page 10 D. Reports c. RCIT VERIFICATION NOT RECEIVED AFTER 90 DAYS This inhibiting edit displays if a client with major program FF, JJ, KK, BB or LL, is P41 or A00 and the DATE REQUESTED date on RCIT is equal to or greater than 90 days ago. d. MAJOR PROGRAM DOES NOT MATCH VERIFICATION CODE ON RCIT This inhibiting edit displays if a client has a major program of JJ or KK and the U.S. CITIZENSHIP / IMMIGRATION VERIFICATION field is coded with a 1 Citizenship Documents Received or 2 Citizenship Documents Needed. d. CANNOT PEND FOR ONLY CITIZENSHIP This warning message displays when a client is pending and the only unresolved pending reason code that exists on RIND is 81 Need Citizenship Verification. This warning message does not inhibit eligibility. e. WARNING: REVIEW CITIZENSHIP EXEMPTION CODING ON RCIT This warning message displays if a client with major program FF, JJ, KK, BB or LL is P41 or A00 and the U.S. CITIZENSHIP/IMMIGRATION VERIFICATION field on RCIT is coded with a 6 Exempt. Two new ereports (previously called InfoPac reports) will be available beginning in September 2010: 1. Citizenship/Immigration Verification Not Received (ereport #MW0337) This report identifies clients who have been closed or denied because they did not provide citizenship or immigration verification within 90 days. This monthly report is available 12 business days before the end of each month. This report provides a list of cases that MMIS closed for failure to provide proof of citizenship or immigration status. Review the client s case to ensure MinnesotaCare was closed correctly. If the client is not cooperating and no documentation of citizenship or immigration status is on file, MinnesotaCare remains closed. 2. Cooperation with Citizenship Verification Requirements (ereport #MW0338) This report identifies clients with major program FF, JJ, KK, BB or LL, who are: P41 or A00, U.S. CITIZENSHIP/IMMIGRATION VERIFICATION field is coded 5- COOPERATING, and

Page 11 Have a SECOND REQUEST date that is greater than or equal to 180 days (six months) ago. This monthly report is available 12 business days before the end of each month. Review case notes to determine if these clients are cooperating with citizenship or immigration documentation requirements. Contact these clients by phone or mail to confirm they are still cooperating and to determine the status of the documentation. III. Case Examples Example 1: Clark and his daughters Kale and Cara apply for MinnesotaCare. Clark provides a copy of his U.S. passport. He does not submit citizenship documentation for Kale or Cara. There are SSA Data Match results in MAXIS on STAT/MEMI for Kale indicating that she is a U.S. citizen. No citizenship documentation is found for Cara. Action: 1. On Clark s RCIT screen, code the U.S. Citizenship/Immigration Verification field 1 Citizenship Documents Received and the TYPE field 02 Passport. Complete the Identity Verification Received field based on documentation received. 2. On Kale s RCIT screen, code the U.S Citizenship/Immigration Verification field 1 Citizenship Documents Received and the Type field as 01 SSA Data Match. Complete the identity Verification Received field based on documentation received. 3. On Cara s RCIT screen, code the U.S. Citizenship/Immigration Verification Field 2 Citizenship Documents Needed and leave the TYPE field blank. MMIS will auto-populate the Date Requested field effective the day the case is approved pending awaiting payment (P41). Complete Cara s Identity Verification Received field as N and update the Date Requested field effective the day Cara s eligibility is approved. Example 2: Ken and Elisha apply for MinnesotaCare for themselves and their son, Roy. MinnesotaCare was previously closed for all household members for failure to provide documentation of citizenship. MMIS will prevent MinnesotaCare approval until the clients submit citizenship documentation. They did not submit citizenship documentation with the new HCAPP but meet all other eligibility criteria for MinnesotaCare.

Page 12 Action: 1. Code the RCIT screen U.S. Citizenship/Immigration Verification fields as 2 Citizenship Documents Needed for each client. 2. The dates on RCIT from the previous closure cannot be changed and will prevent approval of P33 and P41 eligibility results. 3. On the RIND screen for each client, enter 81 Need Citizenship Verification. 4. Pend eligibility P32 and P30 on RELG until proof of citizenship is submitted. 5. Once proof of citizenship is submitted, change the RCIT screen U.S. Citizenship/Immigration Verification field to 1 Citizenship Documents Received and code the identity fields accordingly. Example 3: Helen and Troy s MinnesotaCare case closes for premium non-payment (C22) on August 31. They have also not provided citizenship documentation in over 90 days. Because the case closed for premium non-payment, MMIS did not notify them that their case is also closing for failure to submit citizenship documentation. Helen and Troy pay their premium on September 10 and reinstate their case. Action: No action is required. Because the case was reinstated prior to 13 days before the end of the month, MMIS will send a closing notice to the clients for failure to submit proof of citizenship. If the case was not reinstated prior to 13 days before the end of the month, MMIS will not close MinnesotaCare until the end of the following month, in this case October. Example 4: George and Mae apply for MinnesotaCare for themselves and their children, Harriet and Abe. George states they are all U.S. citizens but does not submit proof of citizenship for himself and Abe. The application is processed on May 10 and they pay their premium on May 20. MinnesotaCare coverage begins for all household members on June 1. George does not provide the citizenship documentation for himself or Abe within 90 days. MMIS closes George and Abe s MinnesotaCare coverage August 31. The August ereport (#MW0337) notifies the worker that George and Abe closed for failure to provide proof of citizenship. Action: Review the case to determine if MMIS closed MinnesotaCare correctly. George and Abe s MinnesotaCare eligibility will remain closed until they provide the required proofs. The All or Nothing rule does not apply and Harriet and Mae remain open on MinnesotaCare.

Page 13 Example 5: Leng s MinnesotaCare eligibility was closed by MMIS on July 31 for failure to submit requested immigration documentation. Leng contacts his worker on August 5 to request reinstatement. Action: Treat Leng s request as a reapplication. Since Leng already had over 90 days to provide proof of immigration status, pend MinnesotaCare eligibility until verifications are received. Leng is not eligible for retroactive coverage so he will have a gap in coverage. IV. Attachments Attachment A: New Codes for TYPE Field on RCIT. The following are MMIS system-generated notices: Attachment B: Attachment C: Attachment D: Attachment E: Minnesota Health Care Programs 1st Request for Proof of Citizenship and Identity. MinnesotaCare 1 st Request for Proof of Immigration Status. Minnesota Health Care Programs 2nd Request for Proof of Citizenship and Identity. MinnesotaCare 2nd Request for Proof of Immigration Status. V. Legal Reference Children s Health Insurance Program Reauthorization Act of 2009 (P.L. 111-3) VI. Americans with Disabilities Act (ADA) Advisory This information is available in alternative formats to individuals with disabilities by calling (651) 431-2283 (voice) or toll free at (888) 938-3224). TTY users can call through Minnesota Relay at (800) 627-3529. For Speech-to-Speech, call (877) 627-3848. For additional assistance with legal rights and protections for equal access to human services programs, contact your agency s ADA coordinator.

NEW CODES FOR TYPE FIELD ON RCIT Attachment A Old Code Definition New Code -- SSA DATA MATCH* 01 01 US PASSPORT* 02 02 PASS CARD* 03 03 CERTIFICATE OF NATURALIZATION* 04 04 CERTIFICATE OF CITIZENSHIP* 05 05 SDX MATCH* 06 06 TRIBAL DOCUMENTATION* 07 08 US PUB BIRTH REC</=5YRS BIRTH 08 09 CERT REPORT OF BIRTH 09 10 CERT OF BIRTH ABROAD 10 11 REPT OF BIRTH ABROAD 11 12 US CITIZEN ID CARD 12 13 AMERICAN INDIAN ID CARD 13 14 NORTHERN MARIANA CARD 14 15 FINAL ADOPTION DECREE/LETTER 15 16 GOV EMPLOYEE BEFORE 6/1/76 16 17 US MILITARY RECORD 17 18 SAVE VERIF. FOR NAT. CITIZN 18 19 HOSPITAL RECORD 19 20 INSURANCE RECORD 20 21 RELIGIOUS RECORD 21 22 SCHOOL RECORD 22 23 FEDERAL/STATE CENSUS REC 23 24 SENECA TRIBAL CENSUS REC 24 25 BIA CENSUS RECORD NAVAJO 25 26 BIA CENSUS REC ALASKA NATIVE 26 27 STATE VITAL STAT NOTICE 27 28 SIGNED DR/MIDWIFE STMT 28 29 INST ADMISSION PAPERS 29 30 MEDICAL RECORD 30 31 US PUB BIRTH REC >5YRS BIRTH 31 32 AFFIDAVITS 32 33 OTHER 33 -- IMMIG DOCUMENTS SEE RIMG* 34 99 EXEMPT 99 *code has changed

Attachment B Minnesota Health Care Programs 1st Request for Proof of Citizenship and Identity ATTN: MINNESOTA DEPARTMENT OF HUMAN SERVICES PO Box 64960 St. Paul, MN 55164-0960 Date Case Name: Case #: Client ID #: Worker number Recipient Address Why am I getting this letter? We are writing to tell you we need proof of citizenship or national status and proof of identity for the persons listed below: What do I need to do? You must give us proof of citizenship and identity for each person listed above. Proof can be a copy of one of the following documents: o U.S. passport o Certificate of Naturalization o Certificate of Citizenship o PASS card o Tribal enrollment or membership card, or o Certificate of degree of Indian blood issued by a federally recognized Indian tribe. If you do not have one of the proofs listed above, you must give us both a citizenship and identity document. See the back of this letter for a list of proofs you can give us. What will happen if I do not give you proof? Some or all family members may not be able to get MinnesotaCare or coverage may end if you do not give us proof by {date}. Questions Call your worker at {worker phone number} if you have questions or need help getting proof.

Attachment B Minnesota Health Care Programs 1st Request for Proof of Citizenship and Identity Citizenship and Identity Proofs You may give us a copy of one of the following documents to prove both citizenship and identity: o U.S. passport o Certificate of Naturalization o Certificate of Citizenship o PASS card o Tribal enrollment or membership card, or o Certificate of degree of Indian blood issued by a federally recognized Indian tribe. If you do not have one of the above proofs, you must give us one citizenship proof and one identity proof for each person. Give us a copy of the first citizenship proof you have on the Citizenship proofs list and one proof on the Identity proofs list below for each person. Citizenship proofs: Birth certificate or other birth document from the U.S. Department of State. U.S. citizen ID card. American Indian card (I-872) from the U.S. Department of Homeland Security. Final U.S. adoption papers. Papers showing U.S. government employment before June 1976. Official military record of service showing United States place of birth. Hospital record showing birth in the United States. Examples include hospital chart pages with notes of the birth or a record of a baby s hospital stay after birth. Insurance company record showing United States as the place of birth. Federal or state census record showing U.S. citizenship or place of birth. Medical records from a clinic, doctor or hospital showing United States as the place of birth. Records must be from within the last five years. A statement signed by a doctor or midwife who was at the birth. Statement must be from within the last five years. Institutional admission papers showing the United States as the place of birth. Papers must be from within the last five years. Proof of identity State driver s license or state ID card with picture School ID card with picture Military ID card or draft record For a child under age 16: o school records including report card o clinic, doctor or hospital records, or o day care records.

Attachment C MinnesotaCare 1 st Request for Proof of Immigration Status ATTN: MINNESOTA DEPARTMENT OF HUMAN SERVICES PO Box 64960 St. Paul, MN 55164-0960 Date Case Name: Case #: Client ID #: Worker number Recipient Address Why am I getting this letter? We are writing to tell you we need proof of immigration status for the persons listed below: What do I need to do? You must give us proof of immigration status for each person listed above. Send a copy of immigration cards or papers for each person. Copy the front and back of each card or paper. Write your case number on each copy. If you do not have proof of immigration status, ask for proof from the United States Citizenship and Immigration Services (USCIS) by calling (800) 375-5283. Call (800) 767-1833 if you are hearing impaired. You can also go to their office or ask for proof in writing at the following address: USCIS St. Paul District 2901 Metro Drive Suite 100 Bloomington, MN 55425 What will happen if I do not give you proof? Some or all family members may not be able to get MinnesotaCare or coverage may end if you do not give us proof by {date}. Questions Call your worker at {worker phone number} if you have questions or need help getting proof.

Attachment D Minnesota Health Care Programs 2nd Request for Proof of Citizenship and Identity ATTN: MINNESOTA DEPARTMENT OF HUMAN SERVICES PO Box 64960 St. Paul, MN 55164-0960 Date Case Name: Case #: Client ID #: Worker number Recipient Address Why am I getting this letter? We are writing to tell you we have not received proof of citizenship or national status and proof of identity for the persons listed below: What do I need to do? You must give us proof of citizenship and identity for each person listed above. Proof can be a copy of one of the following documents: o U.S. passport o Certificate of Naturalization o Certificate of Citizenship o PASS card o Tribal enrollment or membership card, or o Certificate of degree of Indian blood issued by a federally recognized Indian tribe. If you do not have one of the proofs listed above, you must give us both a citizenship and identity document. See the back of this letter for a list of proofs you can give us. What will happen if I do not give you proof? Some or all family members may not be able to get MinnesotaCare or coverage may end if you do not give us proof by {date}. Questions Call your worker at {worker phone number} if you have questions or need help getting proof.

Attachment D Minnesota Health Care Programs 2nd Request for Proof of Citizenship and Identity Citizenship and Identity Proofs You may give us a copy of one of the following documents to prove both citizenship and identity: o U.S. passport o Certificate of Naturalization o Certificate of Citizenship o PASS card o Tribal enrollment or membership card, or o Certificate of degree of Indian blood issued by a federally recognized Indian tribe. If you do not have one of the above proofs, you must give us one citizenship proof and one identity proof for each person. Give us a copy of the first citizenship proof you have on the Citizenship proofs list and one proof on the Identity proofs list below for each person. Citizenship proofs: Birth certificate or other birth document from the U.S. Department of State. U.S. citizen ID card. American Indian card (I-872) from the U.S. Department of Homeland Security. Final U.S. adoption papers. Papers showing U.S. government employment before June 1976. Official military record of service showing United States place of birth. Hospital record showing birth in the United States. Examples include hospital chart pages with notes of the birth or a record of a baby s hospital stay after birth. Insurance company record showing United States as the place of birth. Federal or state census record showing U.S. citizenship or place of birth. Medical records from a clinic, doctor or hospital showing United States as the place of birth. Records must be from within the last five years. A statement signed by a doctor or midwife who was at the birth. Statement must be from within the last five years. Institutional admission papers showing the United States as the place of birth. Papers must be from within the last five years. Proof of identity State driver s license or state ID card with picture School ID card with picture Military ID card or draft record For a child under age 16: o school records including report card o clinic, doctor or hospital records, or o day care records.

Attachment E MinnesotaCare 2nd Request for Proof of Immigration Status ATTN: MINNESOTA DEPARTMENT OF HUMAN SERVICES PO Box 64960 St. Paul, MN 55164-0960 Date Case Name: Case #: Client ID #: Worker number Recipient Address Why am I getting this letter? We are writing to tell you we have not received proof of immigration status for the persons listed below: What do I need to do? You must give us proof of immigration status for each person listed above. Send a copy of immigration cards or papers for each person. Copy the front and back of each card or paper. Write your case number on each copy. If you do not have proof of immigration status, ask for proof from the United States Citizenship and Immigration Services (USCIS) by calling (800) 375-5283. Call (800) 767-1833 if you are hearing impaired. You can also go to their office or ask for proof in writing at the following address: USCIS St. Paul District 2901 Metro Drive Suite 100 Bloomington, MN 55425 What will happen if I do not give you proof? Some or all family members may not be able to get MinnesotaCare or coverage may end if you do not give us proof by {date}. Questions Call your worker at {worker phone number} if you have questions or need help getting proof.