Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 20 - Division of County Operations
Rule 016.20.15-002 - Medical Services Policy D-371-373 and Appendix C

1. An individual placed in an out-of-state institution is a resident of the State making arrangement for placement regardless of the individual's indicated intent or ability to indicate intent;

2. An individual receiving State Supplementation of SSI is a resident of the State making said payments;

3. A non-institutionalized individual age 21 or over is a resident of the State where he is living, and a. Intends to remain permanently or for an indefinite period of time, or b. which he entered with a job commitment or seeking employment.

Exception: An individual aged 18-22 and a full-time student at an Arkansas school, is not a resident of Arkansas if:

4. An institutionalized individual who became incapable of indicating intent at or after age 21 is a resident of the State where the institution is located, unless another state arranged placement in the institution.

5. An institutionalized individual who became incapable of indicating intent before age 21 is a resident of the State of:

6. For any other institutionalized individual not covered by step #4 or #5 above, the individual is a resident where he/she is living and intends to reside.

When more than one State could be an individual's residence, and you cannot determine the jurisdiction of residence based on the above rules, the residence is where the individual is physically located at present.

T Note: For purposes of State residency - an institution is a Title XIX Long Term Care Facility and an individual is considered to be incapable of indicating intent to reside in the State if:

1. An individual will not be denied Medicaid because he has not resided in the State for a specific period;

2. An institutionalized individual, who satisfies the residency rules set forth in this policy, will not be denied Medicaid because he did not establish residence in the State before entering the institution; and

3. An individual will not be denied Medicaid or have his Medicaid terminated because of temporary absence from the State if he intends to return when the purpose of the absence has been accomplished, unless another State has determined that he is a resident there for purposes of Medicaid.

1. They do not stipulate criteria which result in loss of residency in both States or criteria which are prohibited by regulation, and

2. They stipulate procedures for providing Medicaid to individuals whose cases are involved in disputed residency.

As the State of Arkansas enters into written agreement with other States to resolve cases of disputed residency, the County Office will be notified. The notification will identify the State(s) and the criteria of the agreement(s).

1. A State, that has not entered into a written agreement with the State of Arkansas, contacts the County Office regarding Arkansas residents receiving care out-of-state, or

2. The County Office has cases involving possible out-of-state residency.

1. Institutions for the mental diseases which are hospitals, nursing facilities, or other institutions of more than 16 beds that are primarily engaged in providing diagnosis, treatment or care of persons with mental diseases.

2. Institutions for tuberculosis, which are primarily engaged in providing diagnosis, treatment, or care of persons with tuberculosis.

3. Correctional or holding facilities for individuals, who are prisoners, arrested, or detained pending dispositions of charges, or are being held under court order as material witness or juveniles. Correctional facilities include prisons, jails, juvenile detention centers and other facilities operated primarily for the detention of children who are determined to be delinquent. Wilderness camps and boot camps are considered public institutions if a government unit has any degree of administration control.

If an individual in a public institution must be temporarily transferred to a medical treatment or evaluation facility, or if he/she is given temporary furlough, the individual is still considered to be under custody of the penal system and is not eligible for a Medicaid payment. See exception at D-372.

An individual will be considered in a public institution until the indictment against the individual is dismissed, or until he/she is released from custody either as "not guilty" or for some other reason (bail, parole, pardon, suspended sentence, home release program, probation, etc.).

1. Inpatient psychiatric facilities for individuals under age 21 (22, if an inpatient on the 21st birthday) and over age 65.

2. Medical institutions which are organized to provide medical, nursing, and convalescent care, which have the professional staff, equipment and facilities to manage the medical, nursing and other health needs of patients in accordance with accepted standards, and which are authorized under State law to provide medical care. Medical institutions include hospitals and nursing facilities.

3. Intermediate care facilities for those individuals with intellectual disabilities which meet the standards under 42 CFR 483.440(a) for providing active treatment for such individuals or individuals with related conditions.

4. Child-care institutions which are private, non-private, or public that accommodate no more than twenty five (25) children and are licensed by the State or approved by the State agency responsible for licensing or approval of such institutions.

5. Therapeutic Group Homes, Residential Treatment facilities, Emergency Shelters and Therapeutic Foster Homes which meet facility and staffing requirements of the Minimum Licensing Standards for Child Welfare Agencies published by the Child Welfare Agency Review Board.

6. Publically operated community residences that serve no more than 16 residents are facilities that provide some services beyond food and shelter such as social services, help with personal living activities, or training in socialization and life skills. They cannot be on the grounds of or immediately adjacent to any large institution or multiple purpose complexes such as educational or vocational training institutions, correctional or holding facilities, or hospitals, nursing facilities or intermediate care facilities for individuals with intellectual disabilities.

I. Citizenship Verification - Acceptable Documents for Proof of Citizenship

When citizenship cannot be verified through the Federal Data Services Hub (FDSH) or the SSA match, the worker must access Vital Records through ARFinds for verification of birth. If citizenship documentation cannot be obtained through Vital Records, specific forms of documentation may be acceptable evidence of citizenship. If an individual presents evidence from the listing of Primary Documentation, no other information is required.

To establish U.S. citizenship, the document must show a U.S. place of birth and that the person is a U.S. citizen. The documents must be original or certified copies. Copies of documents already obtained will be accepted as assumed made from the original unless questionable (e.g. stamped "copy", or unreadable).

In general, the caseworker should obtain primary evidence of citizenship before using the secondary documentation or tertiary list. The following forms of documentation may be accepted:

Primary documentation- The highest reliability that conclusively establishes identification and citizenship.

* A U.S. Passport.

* A Certificate of Naturalization (Department of Homeland Security (DHS) Forms N-550 or N-570).

* A Certificate of U.S. Citizenship (DHS Forms N-560 or N-561).

Secondary documentation- Secondary evidence of citizenship is documentary evidence of satisfactory reliability that is used when primary evidence of citizenship is not available.

* A U.S. birth certificate.

* A Certification of birth issued by the Department of State (Form DS-1350).

* A Report of Birth Abroad of a U.S. Citizen (Form FS-240).

* A Certification of Birth Abroad (FS-545).

* An American Indian Card issued by the Department of Homeland Security with the classification code "KIC". (Issued by DHS to identify U.S. citizen members of the Texas Band of Kickapoos living near the U.S./Mexican border).

* Final adoption decree.

* Evidence of civil service employment by the U.S. government before June 1976.

Revised (08/15)

* An official military record of service showing a U.S. place of birth.

* A Northern Mariana Identification Card (issued by the INS to a collectively naturalized citizen of the United States who was born in the Northern Mariana Islands before November 4, 1986.

Third level documentation- Third level evidence of U.S. citizenship is documentary evidence of satisfactory reliability that is used when neither primary nor secondary evidence of citizenship is available. This documentation includes:

* Extract of U.S. hospital record of birth established at the time of the person's birth, created at least 5 years before the initial application date and indicating a U.S. place of birth.

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

* Religious records recorded in the U.S. within 3 months after the birth which show that the birth occurred in the U.S. showing the date of the birth of the individual or the individual's age at the time the record was made. These must be official records recorded with the religious organization (e.g., baptismal certificates). Entries in a family bible are not considered recorded religious records.

* Early school records which show the name of the child, the date of admission to the school, the date of birth (or age at the time the record was made), a U. S. place of birth, and the name(s) and place(s) of birth of the applicant's parents.

Fourth level documentation - Fourth level evidence of U.S. citizenship is documentary evidence of the lowest reliability. This level should only be used in the rarest of circumstances. This level of evidence is used only when primary evidence is not available, both secondary and third level evidence do not exist or cannot be obtained within the reasonable opportunity period, and the applicant alleges a U.S. place of birth. This documentation includes:

* Federal or State census record showing U.S. citizenship or a U.S. place of birth, as well as the applicant's age.

* Birth records that were recorded with vital statistics 5 years after a birth (a delayed birth record).

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

Revised (08/15)

* Medical (clinic, doctor, or hospital) record which was created at least 5 years before the initial application date and indicates a U.S. place of birth unless the application is for a child under 5.

* Other document that was created at least five years before application for Medicaid. These documents are Seneca Indian tribal census record, Bureau of Indian Affairs tribal census records of the Navaho Indians, U.S. State Vital Statistics official notification of birth registration, an amended U.S. public birth record that is amended more than 5 years after the person's birth or a statement signed by the physician or midwife who was in attendance at the time of birth.

* The Roll of Alaska Natives maintained by the Bureau of Indian Affairs.

* Written affidavit. This should be in rare circumstances when the applicant or recipient cannot provide evidence from another listing.

Written affidavits may be used in circumstances when the state is unable to secure evidence of citizenship from another listing. The affidavits must be supplied by at least two individuals, one of whom is not related to the recipient. Each must attest to having a personal knowledge of the event(s) establishing the recipient's claim of citizenship. Those making affidavits will be subject to prosecution for perjury. If the persons claiming knowledge of another's citizenship has information, which explains why documentary evidence establishing the claim of citizenship does not exist or cannot be readily obtained, the affidavit should contain this information as well.

A second affidavit from the recipient or other knowledgeable individual explaining why documentary evidence does not exist or cannot be readily obtained must also be requested.

II. Identity

If citizenship is verified with a document on the secondary or lower level listed above, providing proof of identity will be required. Acceptable forms of identity are:

III. Alien Status Verification - Using SAVE (Systematic Alien Verification for Entitlement)

When an individual's INS documentation appears valid but does not have the necessary coding to show the alien's status, or the entry or admission date is missing, verification of the alien's status can be obtained through SAVE's automated database, the Alien Status Verification Index (ASVI).

To access the ASVI:

* Using a touch-tone phone, dial the toll-free system number, 1-800-365 -7620.

* Enter the access code, then press the pound (#) sign when instructed by the recorded message.

* Enter the alien registration number when instructed by the recorded message. The alien registration number is a series of digits preceded by the letter "A." Do not enter the "A." If the number is less than nine digits, use zeros at the beginning of the number to make it nine digits. (E.g., if the number is "A12345" enter it as "000012345.")

If a record for the alien is found, the ASVI system will give the alien's:

* Registration number.

* Verification number.

* Last and first name, spelled out.

* Date of birth.

Revised (08/15)

* Status code.

* Country of birth code.

* Social Security number.

* Date of entry.

If no record is found for the alien, the ASVI system will instruct you to "institute secondary verification." When this message is received, use form G-845, Document Verification Request, to request information from INS.

Secondary Documentation of Alien Status

Secondary documentation is the process for obtaining status information from the INS when using form G-845, Document Verification Request, and its supplement.

Obtain secondary documentation only when:

* SAVE instructs you to do so.

* The documentation the individual provided shows an eligible status, but the document itself is expired or appears questionable or not genuine.

* The documentation is a receipt showing that the alien has an eligible status but has applied to INS for a replacement card.

* The INS documentation appears to be genuine and the alien claims to have an eligible status, but necessary codes or dates are missing from the card.

Until verification is received from the INS indicating the individual is a qualified alien, the individual should be treated as a nonqualified alien.

IV. Alien Documentation Chart

The chart below shows the types of documentation that can be used to verify alien status, and additional verification that certain aliens must provide to verify that they are eligible for Medicaid (e.g., the date they were admitted to the U.S., or the date a particular alien status was granted or adjusted).

Revised (08/15)

Medical Services - Appendix C, Verification of Citizenship, Alien Status and SSN Enumeration

*In 1998, the INS changed the name of Form I-551 from "Alien Registration Receipt Card" to "Permanent Resident Card" because the new name more appropriately identifies the individual as having permanent resident status.

If the documentation provided does not contain all the information needed to establish the alien's eligibility, additional verification can be obtained from the INS by contacting them in writing, using form G-845, or by contacting SAVE by phone.

If the documentation provided appears questionable, contact INS in writing using form G-845 to attempt verification of the document, rather than using SAVE.

Revised (08/15)

V. Social Security Number (SSN) Enumeration

SSNs that have mismatched through the electronic verification process will be submitted to the queue with a message that the SSN could not be verified.

To resolve the mismatch, first check for obvious mismatches, (e.g., errors in keying the SSN, sex, name or date of birth). Next check SOLQ to determine if a correction can be made in the system from the SSA data on SOLQ.

Other methods of resolving a mismatch include:

* Viewing the social security card. The name in the system must match the name on the social security card; and

* Viewing a copy of the birth certificate or other proof of age or date of birth mismatch.

Household Cooperation in Clearing the Mismatch

When declared SSNs are returned by SSA as unverified, it is often necessary for the household to furnish the information necessary to resolve the mismatch.

A request for contact must be issued by the caseworker to advise the recipient of the mismatch, what caused the problem (e.g., name is incorrect) and what information must be provided to resolve the problem. The recipient will be given 10 days to furnish the information. If the household does not furnish the needed information by the end of the designated 10-day period an advance notice of adverse action will be issued.

The notice will specify that: