Citizenship and Identification Reference Tables

 

With CalWIN Release 17, the Data Collection window Collect Individual Demographics Detail has been modified with new fields to capture the new citizenship and identity verification requirements to be eligible for full-scope Medi-Cal benefits.

 

The source drop-down menu for these new fields, not only contains selections that meet the citizenship and identity requirements, but also other choices that do not meet the requirements.  Special care should be taken when selecting the source verification.  For example, there are two selections for birth certificate and driver’s license:  Birth Certificate” and “Driver’s License” do not meet the requirement; while “US Public Birth Record-5 yrs” and “Drivers License-US State/Terr” meet the requirement.

 

The following reference tables are provided to identify those source verifications meeting the Medi-Cal citizenship and identity requirements.

 

NOTE:  Selections from these drop-down menus should be based on the actual documents provided, and not on what will work for Medi-Cal to pass correctly.

 

Citizenship Verification – CalWIN Demographic Detail Tab

 

Use CalWIN Verification Source

Document Description

Adoption Decree-US Birthplace

Final Adoption Decree showing the child’s name and a U.S. place of birth.

Am. Indian Card I-872 w/KIC

American Indian Card (I-872) issued by the Department of Homeland Security with the classification code “KIC”.

Amended US Public Birth Record

An amended U.S. public birth record amended more than 5 years after the person’s birth and created at least 5 years before the initial Medicaid application date.

BIA Navaho Tribe Census Record

Bureau of Indian Affairs tribal census record of the Navaho Indians showing a U.S. place of birth and created at least 5 years before the initial Medicaid application date.

Cert of Rpt of Birth DS-1350

Certification of Report of Birth (DS-1350).

Certification of Birth Abroad

Certification of Birth Abroad (Form FS-545).

Collective Naturalization Doc.

U.S. Citizenship Based on Collective Naturalization for certain citizens or residents of Puerto Rico, U.S. Virgin Islands or Northern Mariana Islands (refer to the Citizenship ACWDL for specific documentation requirements for these individuals).

Consular Report Birth Abroad

Consular Report of Birth Abroad of a Citizen of the United States of America (FS-240).

Dr/Midwife Stmt-US Birthplace

Statement signed by the birth physician or midwife who was in attendance at the time of birth showing a U.S. place of birth and created at least 5 years before the initial Medicaid application date.

Hospital Extract-US Birthplace

Extract of a hospital record on hospital letterhead established at the time of the person’s birth showing a U.S. place of birth and created at least 5 years before the initial Medicaid application date.

NOTE:  For a child under age 5, since the record could not have been created at least 5 years before the initial Medicaid application date, it must have been created near the time of birth.

INS Certif. Of Citizenship

Certificate of Citizenship (Form N-560 or N-561).

Insurance Record-US Birthplace

Life or health or other insurance record showing a U.S. place of birth and created at least 5 years before the initial Medicaid application date.

LTC/SNF Admission-US Birthplace

Institutional admission papers from a nursing facility, skilled care facility or other institution showing a U.S. place of birth and created at least 5 years before the initial Medicaid application date.

Medical Record-US Birthplace

Medical (clinic, doctor or hospital but not immunization) record showing a U.S. place of birth and created at least 5 years before the initial Medicaid application date.

NOTE:  For a child under age 5, since the record could not have been created at least 5 years before the initial Medicaid application date, it must have been created near the time of birth.

MEDS CA Birth Record Match

Electronic verification of California birth record information.  Using CalWIN or MEDS On-Line, staff can request for an automated match against the California birth records for individuals born in California.   

Naturalization Papers

Certificate of Naturalization (Form N-550 or N-570).

Northern Mariana ID Card

Northern Mariana Identification Card (I-873).

Seneca Tribal Census Record

Seneca Indian tribal census record showing a U.S. place of birth and created at least 5 years before the initial Medicaid application date.

State of Federal Census

Federal or State census record showing U.S. citizenship or a U.S. place of birth and the person’s age (generally for persons born 1900 through 1950).

US Citizen ID Card I-197/I-179

U.S. Citizen I.D. Card (Form I-197 or I-179).

US Govt Employed before 6/1/76

Evidence of U.S. Government civil service employment before 6/1/76.

US Military Service Record

Official U.S. Military record of service (e.g., DD-214 or similar official document) showing a U.S. place of birth.

US Passport No Limitation

United States Passport - issued without limitation.

US Public Birth Record-5 yrs

U.S. Public Birth Record issued before age 5 showing birth in one of the 50 U.S. states, the District of Columbia, American Samoa, Swain’s Island, Puerto Rico (DOB on or after 1/13/41), Virgin Islands of the U.S. (DOB on or after 1/17/17), Northern Mariana Islands   (DOB after 11/4/86, NMI local time) or Guam (DOB on or after 4/10/1899).

US State Vital Stat Birth Reg.

U.S. State Vital Statistics official notification of birth registration showing a U.S. place of birth and created at least 5 years before the initial Medicaid application date.

Written Affidavit: MC Cit/ID Req

Written Affidavits – requires affidavits signed under penalty of perjury by at least two individuals (other than the applicant or recipient) of whom at least one is not related to the applicant or recipient and who have personal knowledge of the event’s establishing the client’s claim of citizenship and who are able to prove their own citizenship and identity; also requires a separate affidavit signed under penalty of perjury from the applicant/recipient or other knowledgeable individual explaining why documentary evidence of the claim of citizenship does not exist or cannot be readily obtained.


Identification – CalWIN Identification Detail Tab

Use CalWIN Verification Source

Document Description

Cert. Degree of Indian Blood

Certificate of Degree of Indian Blood.

Drivers License-US State/Terr.

Driver’s license issued by U.S. State or Territory with a photograph or other identifying information such as name, age, sex, race, height, weight and eye color.

ID card-State/Fed/Local Govt

Identification card issued by Federal, State, or local government with the same information as a driver’s license (a photograph or other identifying information such as name, age, sex, race, height, weight and eye color).

INS Certif. of Citizenship

Certificate of Citizenship (Form N-560 or N-561).

Medi-Cal SOF Signed by Parent

Medi-Cal Application signed by a parent or guardian stating the date and place of birth for a child under age 16 (acceptable only when an affidavit was not used for citizenship).

Naturalization Papers

Certificate of Naturalization (Form N-550 or N-570).

Other Native Tribe Doc w/Photo

Certificate of Degree of Indian Blood or other U.S. American Indian/Alaskan Native Tribal document with a photograph or other personal identifying information.

School ID with Photograph

School identification card with a photograph.

School Record-Child under 16

School records including nursery/daycare records for a child under age 16.

U.S. Passport

United States passport issued with limitations.

US Coast Guard Merchant Marine

U.S. Coast Guard Merchant Mariner card.

US Military Card/Draft Record

U.S. military card or draft record.

US Military Dependent ID Card

U.S. Military dependent’s identification card.

US Passport No Limitation

United States Passport issued without limitation.

Written Affidavit: MC Cit/ID Req

Written Affidavit signed under penalty of perjury by a parent or guardian stating the date and place of birth for a child under age 16 (acceptable only when an affidavit was not used for citizenship).