General Eligibility Requirements for Medical Assistance

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HAWAII ADMINISTRATIVE RULES

TITLE 17

DEPARTMENT OF HUMAN SERVICES

SUBTITLE 12

MED-QUEST DIVISION

CHAPTER 1714.1

GENERAL ELIGIBILITY REQUIREMENTS FOR MEDICAL ASSISTANCE

Subchapter 1 General Provisions

§17-1714.1-1 Purpose §17-1714.1-2 Right to assistance §17-1714.1-3 Evidence of identity §17-1714.1-4 Determination of age §§17-1714.1-5 to 17-1714.1-9 (Reserved)

Subchapter 2 Social Security Number

§17-1714.1-10 Purpose §17-1714.1-11 Furnishing of social security number §17-1714.1-12 Verification of SSN §17-1714.1-13 Use of SSN §§17-1714.1-14 to 17-1714.1-18 (Reserved)

Subchapter 3 Residency and Institutional Status

§17-1714.1-19 Purpose §17-1714.1-20 Residency requirements §17-1714.1-21 Eligibility requirements for a resident of a public institution §§17-1714.1-22 to 17-1714.1-26 (Reserved)

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Subchapter 4 Citizenship and Non-Citizen Status

§17-1714.1-27 Purpose §17-1714.1-28 Citizen and non-citizen eligibility §17-1714.1-29 Declaration of citizenship and non- citizen status §17-1714.1-30 Verification of citizenship and non- citizen immigration status §17-1714.1-31 Documentary evidence of citizenship §§17-1714.1-32 to 17-1714.1-36 (Reserved)

Subchapter 5 Eligibility Verification

§17-1714.1-37 Purpose §17-1714.1-38 General requirements §17-1714.1-39 Verification of financial information §17-1714.1-40 Use of information and requests of additional information from an individual §§17-1714.1-41 to 17-1714.1-45 (Reserved)

Historical Note: This chapter is based substantially upon repealed chapter 17-1714. [Eff 08/01/94; am 01/29/96; am 01/02/97; am 02/10/97; am 05/17/97; am 12/27/97; am 06/19/00; am 07/10/06; am 09/10/09; am 04/01/10; am 04/30/10; R 09/30/13]

SUBCHAPTER 1

GENERAL PROVISIONS

§17-1714.1-1 Purpose. The purpose of this chapter is to establish the non-financial general eligibility requirements for medical assistance. [Eff 09/30/13] (Auth: HRS §346-14) (Imp: HRS §346- 14; 42 C.F.R. §435.401)

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§17-1714.1-2 Right to assistance. (a) The department shall promptly provide medical assistance without delay to any individual or household who meets all of the applicable eligibility requirements set forth by subtitle 12. (b) An individual shall receive assistance unless determined ineligible for coverage due to the individual’s or household’s failure to provide required verification or meet all Medicaid eligibility requirements. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.930) (Imp: HRS §346-14; 42 C.F.R. §435.930)

§17-1714.1-3 Evidence of identity. (a) The department shall verify the identity of an individual or household member prior to the approval of assistance. (b) Verification of an individual’s identity through a federal or State governmental agency, including but not limited to a public assistance, law enforcement, internal revenue or tax bureau, or corrections agency, or an Express Lane agency, under section 1902 of the Social Security Act, shall be accepted in lieu of documentation required under subsections (c), (d) and (e). (c) For an individual sixteen years of age or older, the department shall accept the following as proof of identity, provided the documentation has a photograph or other identifying information including, but not limited to, name, age, sex, race, height, weight, eye color, or address: (1) Driver’s license issued by a state or U.S. territory; (2) School identification card; (3) U.S. military card or draft record; (4) Identification card issued by the federal or state government; (5) Military dependent’s identification card; (6) Native American tribal documents; or (7) U.S. Coast Guard Merchant Mariner card.

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(d) For an individual under nineteen years of age, the department shall accept documentation from a clinic, doctor, hospital, or school record, including preschool or day care records. (e) Two of the following types of documents containing consistent information that corroborate an individual’s identity, including, but not limited to, employer identification card, high school and college diploma (including high school equivalency diploma), marriage certificate, divorce decree, and property deed or title. (f) If the individual does not have any document(s) specified in subsections (c), (d) and (e), and identity is not verified under subsection (b), the individual may submit an affidavit signed, under penalty of perjury, by another person who can reasonably attest to the individual’s identity. The affidavit shall contain the individual’s name and other identifying information establishing identity, as described in subsection (c) above. The affidavit does not have to be notarized. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.407; 8 C.F.R. §274a.2(b)(1)(v)(B)(1 (Imp: HRS §346-14; 42 C.F.R. §435.407; 8 C.F.R. §274a.2(b)(1)(v)(B)(1 §17-1714.1-4 Determination of age. (a) Verification of an individual's age shall be required when age is a factor in determining eligibility for medical assistance. (b) Verification of an individual’s age through a federal or State electronic service as described in section 17-1714.1-12(b) shall be accepted in lieu of documentation required under subsections (c) and (d). (c) The department may accept documentation that establishes citizenship or immigration status or identity of an individual under subsections 17-1714.1- 31(a), (b) and (d) for purposes of establishing the age of an individual provided that such documentation reflects the date of the birth of the individual. (d) When documentary sources are not available, the statements of relatives or friends who are

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knowledgeable of the individual's circumstances may be accepted as verification of age. The individual’s record shall contain documentation of the: (1) Name of the relatives or friends; and (2) Facts on which the relatives' or friends' knowledge is based. (e) When all reasonable efforts to establish age have failed, an estimate of age based upon an examination by a physician shall be used. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.401, 435.520, 435.956) (Imp: HRS §346-14; 42 C.F.R. §§435.401, 435.520, 435.945, 435.952, 435.956)

§§17-1714.1-5 to 17-1714.1-9 (Reserved).

SUBCHAPTER 2

SOCIAL SECURITY NUMBER

§17-1714.1-10 Purpose. This subchapter establishes the requirement for a social security number (SSN) for determining an individual’s eligibility for medical assistance. [Eff 09/30/13] (Auth: HRS §346-14; 42 CFR §§435.910, 435.920, 435.930, 435.956) (Imp: HRS §346-14; 42 CFR §§435.910, 435.920, 435.930, 435.956)

§17-1714.1-11 Furnishing of social security number. (a) The department shall require, as a condition of eligibility, that each individual applying for medical assistance furnish a SSN, except as provided in paragraph (c). (b) If an individual is unable to furnish a SSN or has not been issued a SSN, the department shall: (1) Assist the applicant in completing an application for a SSN; (2) Obtain evidence required under the SSA regulations to establish the age,

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citizenship or non-citizen status, and the true identity of the individual; and (3) Send the application to SSA or, if there is evidence that the individual has previously been issued a SSN, request that the SSA furnish the number. (c) The following are exceptions to the requirements of subsection (a): (1) The department may give a Medicaid identification number to an individual who: (A) Is born to a Medicaid mother; (B) Is not eligible to receive a SSN; (C) Does not have a SSN and may only be issued a SSN for a valid non-work reason; or (D) Refuses to obtain a SSN because of well-established religious objections as defined in 42 C.F.R. §435.910(h)(3). (2) The identification number may be either a SSN obtained by the department on the individual’s behalf or another unique identifier. (3) A newborn under age one year is not required to provide a SSN. [Eff 09/30/13] (Auth: HRS §§346-14, 346-71; 42 C.F.R. §§435.910, 435.956) (Imp: HRS §346-14; 42 C.F.R. §§435.910, 435.956)

§17-1714.1-12 Verification of SSN. (a) The department shall verify the SSN furnished by an individual with SSA to insure the SSN was issued to that individual, and to determine whether any other SSNs were issued to that individual. (b) To the extent that the SSN information is available through a federal or State electronic service, the department shall obtain verification of the individual’s SSN information through the electronic service from SSA. For purposes of this chapter, “federal electronic service” means a service established by the federal government through which the department may verify certain information with, or

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obtain such information from, federal agencies and other data sources, including the SSA, Department of the Treasury, and the Department of Homeland Security. A “state electronic service” means a service established by the State through which the department may verify certain information with, or obtain such information from, state agencies and other data sources, including the Department of Labor, or other departments as appropriate. (c) If the department is not able to verify the SSN through a federal or State electronic service, the department shall verify the SSN through other means. (d) The department shall not deny or delay medical assistance to an individual who meets all other eligibility requirements pending the issuance or verification of the individual’s SSN by the SSA or if the individual meets one of the exceptions in subsection 17-1714.1-11(c). The individual shall be required to report the SSN to the department immediately upon receipt. (e) When the SSN has been verified, the department shall make a permanent entry to the individual’s electronic account to prevent the unnecessary reverification of the SSN. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.910, 435.920, 435.949, 435.956) (Imp: HRS §346- 71; 42 C.F.R. §§435.910, 435.920, 435.949, 435.956)

§17-1714.1-13 Use of SSN. The department shall notify the individual that the SSN is required by section 1137(a)(1) of the Social Security Act (42 U.S.C. § 1320b-7(a)(1 to: (1) Verify income, eligibility, and benefits for purposes of medical assistance through computer matches authorized under the federal or State electronic services described in section 17-1714.1-12(b); and (2) Complete computer matching to prevent duplicate participation or assistance, to facilitate mass changes in federal benefits, and to verify the accuracy and reliability

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of the information provided by the household under subchapter 5. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.910) (Imp: HRS §346-14; 42 C.F.R. §435.910)

§§17-1714.1-14 to 17-1714.1-18 (Reserved).

SUBCHAPTER 3

RESIDENCY AND INSTITUTIONAL STATUS

§17-1714.1-19 Purpose. The purpose of this subchapter is to describe how an individual’s state of residence is determined for purposes of establishing eligibility for medical assistance. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.403) (Imp: HRS §346-14; 42 C.F.R. §§435.403)

§17-1714.1-20 Residency requirements. (a) An individual shall be considered to be a resident of the State when: (1) Residing or expressing intent to reside in the State, even if the individual does not have a fixed address; (2) Has entered the State with a job commitment or seeking employment (whether or not currently employed); or (3) Is in receipt of State Supplementary Payment (SSP). (b) For an individual under age twenty-one who is capable of indicating intent and who is not eligible for Medicaid based on receipt of assistance under Title IV-E of the Social Security Act and not receiving a State Supplementary Payment who is: (1) Emancipated from their parent(s) or who is married, the state of residence shall be in accordance with subsection (a);

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(2) Not described in paragraph (b)(1), the state of residence is: (A) The state where the individual resides, even if the individual does not have a fixed address; or (B) The state of residency of the parent or caretaker with whom the individual resides. (c) For an institutionalized individual who is neither married nor emancipated, and who: (1) Became incapable of indicating intent to reside before age twenty-one, except as provided in subsection (a)(3), the state of residence is that of the individual’s: (A) Parent(s) or guardian, if one has been appointed; or (B) Parent applying for medical assistance on the individual’s behalf if the parents reside in separate states and there is no appointed legal guardian. (2) Became incapable of indicating intent to reside after age twenty-one, the state of residence is the state in which the individual is physically present, except where another state makes the placement. (d) For purposes of subsection (b), an individual is considered incapable of indicating intent to reside when: (1) The individual’s I.Q. is forty-nine or less, or has a mental age of seven years or less, based on tests acceptable to the intellectual disability agency of the State; (2) The individual is judged legally incompetent; or (3) The individual is found incapable of indicating intent based on medical documentation obtained from a physician, psychologist, or other individual licensed by the State in the field of intellectual disability. (e) When a placement is initiated by a state due to the lack of appropriate facilities to provide

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services to its residents, the state making the placement is the individual’s state of residence. (f) A resident who is eligible for medical assistance and who is temporarily absent from the State with the intent to return when the purpose of the absence has been accomplished, does not interrupt a resident’s State residency unless another state has determined that the individual is a resident there for purposes of Medicaid. Within ninety days of the day of departure, the department shall re-evaluate the individual’s intent to return to the State based on the submission of the following: (1) The intended date of the out-of-state visit and the intended date of return back to the State; and (2) The intended date of return, if an extension from the original date previously submitted was changed. (g) Medical assistance shall be provided to a resident temporarily absent from the State who: (1) Meets all conditions of eligibility for medical assistance as specified in the department rules; and (2) Requires medical services outside the State under circumstances where services were emergent or when it would be impractical to return to the State for the necessary services. (h) The department may have a written agreement with another state setting forth rules and procedures to resolve disputes involving the place of residency. (i) Where two or more states disagree on an individual’s state of residence, the state where the individual is physically located shall be the state of residence. (j) The department shall accept a self- attestation by the individual or attestation by an adult who is in the household, authorized representative, or someone acting responsibly on behalf of a minor or incapacitated individual for information to verify State residency.

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(k) Evidence of immigration status may not be used to determine that an individual is not a State resident. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.403, 435.945, 435.956) (Imp: HRS §346- 14; 42 C.F.R. §§435.403, 435.945, 435.956)

§17-1714.1-21 Eligibility requirements for a resident of a public institution. (a) An individual shall not be eligible for medical assistance when the individual is: (1) An inmate in a public institution; or (2) Under age sixty-five who is a resident or patient in an institution for mental disease or tuberculosis, unless the individual is under age twenty-two and is in receipt of inpatient psychiatric services. (b) An individual described in paragraph (a) shall be eligible for medical assistance during that part of the month in which the individual has been paroled from a public institution, or is on conditional release or convalescent leave from an institution for mental diseases or tuberculosis. (c) An individual on conditional release or convalescent leave from an institution for mental diseases is not considered to be a patient in that institution, unless the individual is under age twenty-two and in receipt of inpatient psychiatric services, until the individual is unconditionally released or, if earlier, reaches age twenty-two years. (d) An individual shall not be considered an inmate of a public institution when the individual is in a public educational or vocational training institution for purposes of securing education or vocational training; or is in a public institution for a temporary period pending other arrangements appropriate to the individual’s needs. (e) An inmate of a public institution may be eligible, provided all other requirements are met, for inpatient services that are provided in a medical institution that is not located on the grounds of the public institution. [Eff 09/30/13] (Auth: HRS

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§§346-14, 346-29; 42 C.F.R. §§435.403, 435.1009, 435.1010) (Imp: HRS §346-29; 42 C.F.R. §§435.403, 435.1009, 435.1010)

§§17-1714.1-22 to 17-1714.1-26 (Reserved).

SUBCHAPTER 4

CITIZENSHIP AND NON-CITIZENSHIP STATUS

§17-1714.1-27 Purpose. The purpose of this subchapter is to establish the types of acceptable documentary evidence of citizenship and non-citizen status that an individual or household shall meet to be eligible for Medicaid. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.406, 435.407) (Imp: HRS §346- 14; 42 C.F.R. §§435.406, 435.407)

§17-1714.1-28 Citizen and non-citizen eligibility. (a) The following individuals meet the citizenship and non-citizen requirements to be eligible for Medicaid: (1) A citizen of the U.S. who has declared that the individual is a citizen or national of the U.S., and the department has verified the declaration under section 17-1714.1-30. For purposes of this subchapter, a citizen of the U.S. includes naturalized citizens, members of a federally-recognized Indian Tribe, and individuals born in the fifty states, the District of Columbia, Puerto Rico, Guam, American Virgin Islands, American Samoa, Swain's Island, or the Commonwealth of the Northern Mariana Islands. (2) A qualified non-citizen: (A) Who is granted asylum under section 208 of the INA (8 U.S.C. § 1158);

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(B) Who is admitted to the U.S. as a refugee under section 207 of the INA (8 U.S.C. § 1157); (C) Whose deportation is being withheld under section 243(h) of the INA (8 U.S.C. § 1253, as in effect immediately before the effective date of section 307 of division C of Public Law 104- 208) or section 241(b)(3) of the INA (8 U.S.C. §1231(b)(3), as amended by section 305(a) of division C of Public Law 104-208); or (D) Who is a Cuban or Haitian refugee or entrant as addressed in Title IV of the Immigration and Nationality Act and section 501 of the Refugee Education Assistance Act. (b) The following qualified non-citizen, who entered the U.S. on or after August 22, 1996, beginning five years after the individual’s entry into the U.S., who is a: (1) Legal permanent resident; (2) Non-citizen who is paroled into the U.S. under section 212(d)(5) of the INA (8 U.S.C. § 1182(d)(5 for a period of at least one year; (3) Non-citizen who is granted conditional entry under section 203(a)(7) of the INA (8 U.S.C. § 1153(a)(7 as in effect prior to April 1, 1980; (4) Non-citizen who has been battered or subjected to extreme cruelty in the U.S. by a spouse, parent, or household member with the spouse or parent’s consent or acquiescence, including a battered child and parent(s) of the battered child (without the active participation of the parent(s) in the battery or cruelty) as described in 8 U.S.C. § 1641(c), and has been approved for or has a petition pending that sets forth a prima facie case to be granted status by USCIS as a battered spouse, a child, or a parent of a

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battered child under clauses (i), (ii), (iii) and (iv) of section 204(a)(1)(A) or clauses (i), (ii) and (iii) of section 204(a)(1)(B) of the INA, provided that the individual responsible for such battery does not reside in the same household as the individual subjected to the battery; or (5) An individual who has been granted nonimmigrant status under section 101(a)(15)(T) of the INA (8 U.S.C. §1101(a)(15)(T as a victim of a severe form of trafficking in individuals or who has a pending application that sets forth a prima facie case for eligibility for such nonimmigrant status, provided that the individual responsible for such cruelty does not reside in the same household as the individual subjected to the cruelty. (c) The following lawfully present non-citizen who is: (1) Admitted to the United States as an Amerasian immigrant pursuant to section 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act, 1988 (as contained in section 101(e) of Public Law 100-202 and amended by the 9th proviso under Migration and Refugee Assistance in title II of the Foreign Operations, Export Financing, and Related Programs Appropriations Act, 1989, Public Law 100-461, as amended; (2) A legal permanent resident who has worked forty qualifying quarters of coverage as defined under title II of the Social Security Act and did not receive any federal means-tested public benefit, other than those listed in 8 U.S.C. §1613(c)(2) for any qualifying quarter after December 31, 1996; (3) An honorably discharged veteran or active member of the U.S. armed forces and the veteran or active member’s spouse or dependent child, or unremarried surviving

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spouse of the deceased veteran, under 8 U.S.C. §1612(b)(2)(C); (4) An American Indian born in Canada subject to section 289 of the INA (8 U.S.C. § 1359), or who is a member of an Indian tribe as defined in 25 U.S.C. §450b(e); (5) In receipt of SSI, or determined to be blind or disabled by the SSA on August 22, 1996; (6) Issued a record of lawful admission for permanent residence under section 249 of the INA (8 U.S.C. § 1259); or (7) A lawfully present non-citizen, including a citizen of a COFA nation, who is under age nineteen years or a pregnant woman. [Eff 09/30/13] (Auth: HRS §§346-14, 346- 71; 42 C.F.R. §435.406; 8 U.S.C. §§1259, 1611, 1612, 1613, 1641) (Imp: HRS §§346-14, 346-71; 42 C.F.R. §435.406; 8 U.S.C. §§1259, 1611, 1612, 1613, 1641)

§17-1714.1-29 Declaration of citizenship and non-citizen status. (a) The department shall provide Medicaid to an otherwise eligible individual who is a citizen: (1) Provided the individual has declared that the individual is a citizen or national of the United States, and the department has verified such declaration; (2) Except the following individuals are exempt from the verification requirement in this subsection: (A) An individual in receipt of foster care services or benefits under Title IV-B or Title IV-E of the Social Security Act; (B) An individual entitled to or enrolled in Medicare; (C) An individual in receipt of disability benefits under Title II of the Social Security Act;

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(D) An SSI recipient under Title XVI of the Social Security Act; and (E) A newborn for the first year of life who is born to a Medicaid beneficiary mother. (b) The department shall provide Medicaid to an otherwise eligible qualified non-citizen provided that the individual has declared that the individual is a qualified non-citizen and has provided satisfactory documentary evidence of status as a qualified non- citizen, and the Department of Homeland Security has verified that the individual is in satisfactory immigration status. (c) For purposes of this section, “satisfactory immigration status” means an immigration status which does not make the individual ineligible for benefits under the applicable program. (d) The declaration of citizenship, national or immigration status and verification requirements for an individual under subsections (a) and (b) may be provided by the individual or an adult member of the individual’s household, an authorized representative, or if the individual is a minor or incapacitated, someone acting responsibly for the individual under a declaration signed under penalty of perjury. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.406, 435.949, 435.956) (Imp: HRS §346-14; 42 C.F.R. §§435.406, 435.949, 435.956)

§17-1714.1-30 Verification of citizenship and non-citizen immigration status. (a) The department shall verify citizenship or non-citizen immigration status through the federal electronic service under section 17-1714.1-12(b). (b) If the department is unable to verify citizenship or immigration status through the federal electronic service, the department shall: (1) Verify citizenship with acceptable documentary evidence and in accordance with section 17-1714.1-31.

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(2) Verify immigration status in accordance with section 1137(d) of the Social Security Act (42 U.S.C. §1320b-7(d)(1)(B)(iii and the requirements of section 17-1714.1-31. (c) If the department is unable to promptly verify the citizenship or non-citizen immigration status of an individual in accordance with subsection (a), the department: (1) Shall provide the individual with a reasonable opportunity to obtain or provide the necessary information in accordance with subsections (e) through (i); and (2) May not delay, deny, reduce or terminate benefits for an individual who is otherwise eligible for Medicaid during the reasonable opportunity period. (d) The department shall maintain a record of having verified citizenship or non-citizen status for each individual, in an electronic database. The department may not re-verify or require an individual to re-verify citizenship or non-citizen status at a renewal or eligibility or subsequent application following a break in coverage. (e) The department shall notify the individual for whom the department is unable to promptly verify citizenship or satisfactory non-citizen status in accordance with chapter 1713.1. (f) During the reasonable opportunity period, the department shall, if relevant to verification of the individual’s status, assist the individual as follows: (1) Assist the individual in obtaining an SSN; (2) Attempt to resolve any inconsistencies between information provided by the individual and data from the electronic service, and resubmit corrected information; (3) Provide information on how to contact the source of the electronic data directly to resolve the issue; and (4) Permit the individual to provide other documentation of citizenship or immigration status.

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(g) The reasonable opportunity period shall begin on and shall extend ninety days from date the individual receives notice from the department that the department was unable to verify citizenship or satisfactory immigration status. The notice is considered to be received by the individual five days after the date of the notice, unless the individual can show it was not received within the five day period. (h) At the department’s option, the reasonable opportunity period may be extended beyond ninety days if the individual provides evidence of a good faith effort to resolve the issue or the department requires additional time to complete the verification process. (i) At the end of the reasonable opportunity period, and any extensions granted by the department, if the individual’s citizenship or non-citizen status has not been verified in accordance with subsection (a), the department shall take action within thirty days to terminate eligibility, subject to the provisions of chapter 17-1703.1. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.407, 435.956) (Imp: HRS §346-14; 42 C.F.R. §§435.407, 435.956)

§17-1714.1-31 Documentary evidence of citizenship. (a) The following documentary evidence of citizenship is acceptable: (1) U.S. passport, including a U.S. Passport Card issued by the Department of State, without regard to any expiration date as long as the passport or Card was issued without limitation; (2) A certificate of U.S. citizenship; (3) A certificate of naturalization; (4) A valid state-issued driver’s license if the state issuing the license requires proof of U.S. citizenship, or obtains and verifies a social security number from the applicant who is a citizen before issuing such license.

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(5) Documentary evidence issued by a federally recognized Indian Tribe, by the Bureau of Indian Affairs within the U.S. Department of the Interior, and including Tribes located in a State that has an international border which: (A) Identifies the federally recognized Indian Tribe that issued the document; (B) Identifies the individual by name; and (C) Confirms the individual’s membership, enrollment, or affiliation with the Tribe. (6) Documents described in paragraph (5) above include, but are not limited to: (A) A Tribal enrollment card; (B) A certificate of degree of Indian blood; (C) A Tribal census document; and (D) Documents on Tribal letterhead, issued under the signature of the appropriate Tribal official, that meet the requirements of paragraph (5). (b) If documentary evidence of citizenship described in subsection (a) are unavailable, the following shall be accepted as satisfactory evidence to establish citizenship if also accompanied by an identity document listed in section 17-1714.1-4: (1) U.S. public birth certificate showing birth in: (A) One of the fifty states; (B) The District of Columbia; (C) Guam; (D) American Samoa; (E) Swain’s Island; (F) Puerto Rico (if born on or after January 13,1941); (G) U.S. Virgin Islands (if born on or after January 17,1917); (H) The Commonwealth of Northern Mariana Islands (CNMI) (if born on or after November 4, 1986);

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(I) If the birth record document issued by the State, commonwealth, territory or local jurisdiction shows the individual was born in Puerto Rico, the U.S. Virgin Islands or the CNMI before these areas became part of the U.S., the individual may be a collectively naturalized citizen. (2) Certification of report of birth, issued to a U.S. citizen who was born outside the U.S.; (3) Report of birth abroad of a U.S. citizen; (4) Certification of birth (5) U.S. citizen identification card; (6) Northern Marianas identification card, issued to a collectively naturalized citizen, who was born in the CNMI before November 4, 1986; (7) Documentation that a child meets the requirements of section 101 of the Child Citizenship Act of 2000 (8 U.S.C. §1431); (8) Final adoption decree or if an adoption is not final, a statement from a state-approved adoption agency with child’s name and U.S. place of birth; (9) Evidence of U.S. civil service employment by the U.S. government before June 1, 1976; (10) U.S. military record of service showing a U.S. place of birth; (11) Verification with the Department of Homeland Security’s Systematic Alien Verification for Entitlements (SAVE) database or any other process established by the Department of Homeland Security to verify an individual is a citizen; (12) Medical records, including, but not limited to, hospital, clinic, or doctor records or admission papers from a nursing facility, skilled care facility, or other institution that indicate a U.S. place of birth; (13) A life, health, or other insurance record that indicates a U.S. place of birth;

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(14) An official religious record recorded in the U.S. showing the birth occurred in the U.S.; (15) School records, including pre-school, Head Start and daycare, showing the child’s name and a U.S. place of birth; (16) A federal or State census record showing U.S. citizenship or a U.S. place of birth; (17) At the department’s option, a cross match with a State department of vital statistics documenting a record of birth; (c) If the individual does not have one of the documents listed in subsections (a) or (b), submission of an affidavit signed by another individual who can reasonably attest to the individual’s citizenship shall be accepted. The affidavit shall be signed under penalty of perjury and contain the individual’s name, date of birth, place of U.S. birth, and does not have to be notarized. (d) The department may rely on a verification of citizenship made by a federal agency or another State agency, without further documentation of citizenship or identity, if such verification was done on or after July 1, 2006. (e) The department shall provide assistance to individuals who need assistance in securing satisfactory documentary evidence of citizenship in a timely manner. (f) A photocopy, facsimile, scanned or other copy of a document shall be accepted to the same extent as an original document under this section, unless information on the submitted document is inconsistent with other information available to the department or the department otherwise has reason to question the validity of the document or the information on the document. (g) An individual unable to furnish the required documents or an affidavit shall not be eligible for medical assistance. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.406, 435.407, 435.912, 435.930) (Imp: HRS §346-14; 42 C.F.R. §§435.406, 435.407, 435.912, 435.930)

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§§17-1714.1-32 to 17-1714.1-36 (Reserved).

SUBCHAPTER 5

ELIGIBILITY VERIFICATION

§17-1714.1-37 Purpose. This subchapter is to identify the federal, State or other available data sources and how the department will use and process the information obtained from these matches to determine eligibility for medical assistance. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.940) (Imp: HRS §346-14; 42 C.F.R. §435.940)

§17-1714.1-38 General requirements. (a) The department shall accept self-attestation of an individual, attestation by an adult individual who is in the applicant’s household, an authorized representative, or, if the individual is a minor, incapacitated or deceased, someone acting on the applicant’s behalf, without requiring further information or documentation, except as allowed under section 17-1714.1-40 or where the law or this chapter requires other procedures, such as for verifying citizenship, immigration status, and SSN. (b) The department shall request and use information relevant to verifying an individual’s eligibility for Medicaid as described in this subchapter. (c) The department shall furnish in a timely manner income and eligibility information, subject to chapter 1702, required for verifying eligibility to the following programs: (1) Other agencies in the State and other states and to the federal programs both listed in section 17-1711.1-34 and identified in section 1137(b) of the Social Security Act; (2) Other insurance affordability programs;

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(3) The child support enforcement program under Part D of title IV of the Social Security Act; and (4) SSA for OASDI under title II and for SSI under title XVI of the Social Security Act. (d) All state eligibility determination systems shall conduct data matching through the Public Assistance Reporting Information System (PARIS). (e) Prior to requesting information for an individual from another agency or program under this subchapter, the department shall inform the individual that the department will obtain and use information available under this subchapter to verify income and eligibility or for other purposes directly connected to the administration of the State Plan. (f) Information exchanged electronically between the department and any other agency or program shall be sent and received via secure electronic interfaces. (g) The department shall execute written agreements with other agencies before releasing data to, or requesting data from, those agencies. These agreements shall provide for appropriate safeguards limiting the use and disclosure of information as required by federal or State law or regulations. (h) The department may request and use information from alternative sources other than those listed in section 17-1714.1-40, or through a mechanism other than the federal and state electronic services, provided it will reduce the administrative costs and burdens on an individual and states while maximizing accuracy, minimizing delay, meeting applicable requirements relating to the confidentiality, disclosure, maintenance, or use of information, and promoting coordination with other insurance affordability programs. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.945) (Imp: HRS §346-14; 42 C.F.R. §435.945)

§17-1714.1-39 Verification of financial information. (a) The department shall request from other agencies in the State or other states and

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federal programs the following information to verify financial eligibility of an individual: (1) Information related to wages, net earnings from self-employment, unearned income and resources from the State Wage Information Collection Agency (SWICA), the Internal Revenue Service(IRS), the Social Security Administration (SSA), the agencies administering the State unemployment compensation laws, the State-administered supplementary payment programs under section 1616(a) of the Social Security Act, and any State program administered under Titles I, X, XIV, or XVI of the Social Security Act; and (2) Information related to eligibility or enrollment from the Supplemental Nutrition Assistance Program (SNAP), the State program funded under Title IV-A of the Social Security Act, and other insurance affordability programs. (b) If the information identified in paragraph (a) is available through the federal and state electronic services the department shall obtain the information through these services. (c) The department shall request the information by an SSN or other personally identifying information in the individual’s electronic account, if possible. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.948, 435.949) (Imp: HRS §346-14; 42 C.F.R. §§435.948, 435.949)

§17-1714.1-40 Use of information and requests of additional information from an individual. (a) The department shall promptly evaluate the information it receives or obtains in accordance with this chapter to determine whether the information may affect the eligibility or benefits of an individual. (b) If the information provided by or on behalf of an individual is reasonably compatible with information obtained through an electronic service,

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the agency shall determine or renew eligibility based on such information. (c) An individual shall not be required to provide additional information or documentation unless information needed by the department cannot be obtained electronically or the information obtained electronically is not reasonably compatible with information provided by or on behalf of the individual. (1) Income information obtained through an electronic service shall be considered reasonably compatible with income information provided by or on behalf of an individual if both are either above, at or below the applicable income standard or other relevant income threshold within an amount as determined by the department. (2) If the information provided by or on behalf of an individual is not reasonably compatible with the electronic service, the department shall pursue additional information from the individual, including: (A) A statement which reasonably explains the discrepancy; or (B) Other information, provided that documentation from the individual is permitted only to the extent electronic data is not available and establishing a data match through an electronic service would not be feasible; (C) The department shall provide the individual a reasonable period to furnish any additional information required under this subsection. (d) The department shall permit on a case-by- case basis for special circumstances, except for citizenship and immigration status, self-attestation of an individual for all eligibility requirements when documentation does not exist at the time of application or is not reasonably available, such as for an individual who: (1) Is homeless;

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(2) Experienced domestic violence; (3) Was in a natural disaster; or (4) As otherwise determined by the department. (e) The department may not deny or terminate eligibility or reduce benefits for any individual on the basis of information received under this subchapter unless the department pursued additional information from the individual in accordance with subsection (c) and provided proper notice and hearing rights in accordance with chapters 17-1703.1 and 17- 1712.1. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.952) (Imp: HRS §346-14; 42 C.F.R. §435.952)

§§17-1714.1-41 to 17-1714.1-45 (Reserved).

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