441—75.11 (249A) Citizenship or alienage requirements.
	 75.11(1) Definitions.
“Care and services necessary for the treatment of an emergency medical condition” shall mean services provided in a hospital, clinic, office or other facility that is equipped to furnish the required care after the sudden onset of an emergency medical condition, provided the care and services are not related to an organ transplant procedure furnished on or after August 10, 1993. Payment for emergency medical services shall be limited to the day treatment is initiated for the emergency medical condition and the following two days.
“Emergency medical condition” shall mean a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:
	  1. 	 Placing the patient’s health in serious jeopardy.
	  2. 	 Serious impairment to bodily functions.
	  3. 	 Serious dysfunction of any bodily organ or part.
“Federal means-tested program” means all federal programs that are means-tested with the exception of:
	  1. 	 Medical assistance for care and services necessary for the treatment of an emergency medical condition not related to an organ transplant procedure furnished on or after August 10, 1993.
	  2. 	 Short-term, non-cash, in-kind emergency disaster relief.
	  3. 	 Assistance or benefits under the National School Lunch Act.
	  4. 	 Assistance or benefits under the Child Nutrition Act of 1966.
	  5. 	 Public health assistance (not including any assistance under Title XIX of the Social Security Act) for immunizations with respect to immunizable diseases and for testing and treatment of symptoms of communicable diseases whether or not the symptoms are caused by a communicable disease.
	  6. 	 Payments of foster care and adoption assistance under Parts B and E of Title IV of the Social Security Act for a parent or a child who would, in the absence of numbered paragraph “1,” be eligible to have payments made on the child’s behalf under such part, but only if the foster or adoptive parent (or parents) of the child is a qualified alien (as defined in Section 431).
	  7. 	 Programs, services, or assistance (such as soup kitchens, crisis counseling and intervention, and short-term shelter) specified by the attorney general of the United States in the attorney general’s sole and unreviewable discretion after consultation with appropriate federal agencies and departments, that:
	  ● 	 Deliver in-kind services at the community level, including through public or private nonprofit agencies;
	  ● 	 Do not condition the provision of assistance, the amount of assistance provided, or the cost of assistance provided on the individual recipient’s income or resources; and
	  ● 	 Are necessary for the protection of life or safety.
	  8. 	 Programs of student assistance under Titles IV, V, IX, and X of the Higher Education Act of 1965, and Titles III, VII, and VIII of the Public Health Services Act.
	  9. 	 Means-tested programs under the Elementary and Secondary Education Act of 1965.
	  10. 	 Benefits under the Head Start Act.
	  11. 	 Benefits funded through an employment and training program of the U.S. Department of Labor.
“Qualified alien” means an alien who is:
	  1. 	 Lawfully admitted for permanent residence under the Immigration and Nationality Act;
	  2. 	 Granted asylum under Section 208 of the Immigration and Nationality Act;
	  3. 	 A refugee and who is admitted to the United States under Section 207 of the Immigration and Nationality Act;
	  4. 	 Paroled into the United States under Section 212(d)(5) of the Immigration and Nationality Act for a period of at least one year;
	  5. 	 An alien whose deportation is being withheld under Section 243(h) of the Immigration and Nationality Act; or
	  6. 	 Granted conditional entry pursuant to Section 203(a)(7) of the Immigration and Nationality Act, as in effect prior to April 1, 1980.
“Qualifying quarters” includes all of the qualifying quarters of coverage as defined under Title II of the Social Security Act worked by a parent of an alien while the alien was under age 18 and all of the qualifying quarters worked by a spouse of the alien during their marriage if the alien remains married to the spouse or the spouse is deceased. No qualifying quarter of coverage that is creditable under Title II of the Social Security Act for any period beginning after December 31, 1996, may be credited to an alien if the parent or spouse of the alien received any federal means-tested public benefit during the period for which the qualifying quarter is so credited.
	 75.11(2) Citizenship and alienage.
	  a.   	 To be eligible for Medicaid a person must be one of the following:
	 (1) 	 A citizen or national of the United States.
	 (2) 	 A qualified alien as defined in subrule 75.11(1) residing in the United States prior to August 22, 1996.
	 (3) 	 A qualified alien who entered the United States on or after August 22, 1996, and who is:
	  ● 	 A refugee who is admitted to the United States under Section 207 of the Immigration and Nationality Act;
	  ● 	 Granted asylum under Section 208 of the Immigration and Nationality Act;
	  ● 	 An alien whose deportation is being withheld under Section 243(h) of the Immigration and Nationality Act; or
	  ● 	 A veteran with a discharge characterized as an honorable discharge and not on account of alienage, an alien who is on active duty in the Armed Forces of the United States other than active duty for training, or the veteran’s spouse or unmarried dependent child.
	 (4) 	 A qualified alien who entered the United States on or after August 22, 1996, and who has resided in the United States for a period of at least five years.
	  b.   	 As a condition of eligibility, each member shall complete and sign Form 470-2549, Statement of Citizenship Status, attesting to the member's citizenship or alien status. When the member is incompetent or deceased, the form shall be signed by someone acting responsibly on the member's behalf. An adult shall sign the form for dependent children.
	 (1) 	 As a condition of eligibility, all applicants for Medicaid shall attest to their citizenship status by signing the application form which contains the same declaration.
	 (2) 	 As a condition of continued eligibility, SSI-related Medicaid members not actually receiving SSI who have been continuous members since August 1, 1988, shall attest to their citizenship status by signing the application form which contains a similar declaration at time of review.
	  c.   	 Except as provided in paragraph “f,” applicants or members for whom an attestation of United States citizenship has been made pursuant to paragraph “b” shall present satisfactory documentation of citizenship or nationality as defined in paragraph “d” or “e.” An applicant or member shall have a reasonable period to obtain and provide proof of citizenship or nationality.
	 (1) 	 For the purposes of this requirement, the “reasonable period” begins on the date a written request to obtain and provide proof is issued to an applicant or member and continues to the date when the proof is provided or the date when the department establishes that the applicant or member is no longer making a good-faith effort to obtain the proof, whichever is earlier.
	 (2) 	 Medicaid eligibility shall continue for members during the reasonable period. Medicaid shall not be approved for applicants until acceptable documentary evidence is provided.
	 (3) 	 A reference to a form in paragraph “d” or “e” includes any successor form.
	  d.   	 Any one of the following documents shall be accepted as satisfactory documentation of citizenship or nationality:
	 (1) 	 A United States passport.
	 (2) 	 Form N-550 or N-570 (Certificate of Naturalization) issued by the U.S. Citizenship and Immigration Services.
	 (3) 	 Form N-560 or N-561 (Certificate of United States Citizenship) issued by the U.S. Citizenship and Immigration Services.
	 (4) 	 A valid state-issued driver’s license or other identity document described in Section 274A(b)(1)(D) of the United States Immigration and Nationality Act, but only if the state issuing the license or document either:
	  1. 	 Requires proof of United States citizenship before issuance of the license or document; or
	  2. 	 Obtains a social security number from the applicant and verifies before certification that the number is valid and is assigned to the applicant who is a citizen.
	 (5) 	 Another document that provides proof of United States citizenship or nationality and provides a reliable means of documentation of personal identity, as the secretary of the U.S. Department of Health and Human Services may specify by regulation pursuant to 42 U.S.C. Section 1396b(x)(3)(B)(v).
	  e.   	 Satisfactory documentation of citizenship or nationality may also be demonstrated by the combination of:
	 (1) 	 Any identity document described in Section 274A(b)(1)(D) of the United States Immigration and Nationality Act or any other documentation of personal identity that provides a reliable means of identification, as the secretary of the U.S. Department of Health and Human Services finds by regulation pursuant to 42 U.S.C. Section 1396b(x)(3)(D)(ii), and
	 (2) 	 Any one of the following:
	  1. 	 A certificate of birth in the United States.
	  2. 	 Form FS-545 or Form DS-1350 (Certification of Birth Abroad) issued by the U.S. Citizenship and Immigration Services.
	  3. 	 Form I-97 (United States Citizen Identification Card) issued by the U.S. Citizenship and Immigration Services.
	  4. 	 Form FS-240 (Report of Birth Abroad of a Citizen of the United States) issued by the U.S. Citizenship and Immigration Services.
	  5. 	 Another document that provides proof of United States citizenship or nationality, as the secretary of the U.S. Department of Health and Human Services may specify pursuant to 42 U.S.C. Section 1396b(x)(3)(C)(v).
	  f.   	 A person for whom an attestation of United States citizenship has been made pursuant to paragraph “b” is not required to present documentation of citizenship or nationality for Medicaid eligibility if any of the following circumstances apply:
	 (1) 	 The person is entitled to or enrolled for benefits under any part of Title XVIII of the federal Social Security Act (Medicare).
	 (2) 	 The person is receiving federal social security disability insurance (SSDI) benefits under Title II of the federal Social Security Act, Section 223 or 202, based on disability (as defined in Section 223(d)).
	 (3) 	 The person is receiving supplemental security income (SSI) benefits under Title XVI of the federal Social Security Act.
	 (4) 	 The person is a child in foster care who is eligible for child welfare services funded under Part B of Title IV of the federal Social Security Act.
	 (5) 	 The person is eligible for adoption or foster care assistance funded under Part E of Title IV of the federal Social Security Act; or
	 (6) 	 The person has previously presented satisfactory documentary evidence of citizenship or nationality, as specified by the United States Secretary of Health and Human Services.
	  g.   	 If no other identity documentation allowed by subparagraph 75.11(2)“e”(1) is available, identity may be documented by affidavit as described in this paragraph. However, affidavits cannot be used to document both identity and citizenship.
	 (1) 	 For children under the age of 16, identity may be documented using Form 470-4386 or 470-4386(S), Affidavit of Identity, signed by the child’s parent, guardian, or caretaker relative under penalty of perjury.
	 (2) 	 For disabled persons who live in a residential care facility, identity may be documented using form 470-4386 or 470-4386(S), Affidavit of Identity, signed by a residential care facility director or administrator under penalty of perjury.
	  h.   	 If no other documentation that provides proof of United States citizenship or nationality allowed by subparagraph 75.11(2)“e”(2) is available, United States citizenship or nationality may be documented using Form 470-4373 or 470-4373(S), Affidavit of Citizenship. However, affidavits cannot be used to document both identity and citizenship.
	 (1) 	 Two affidavits of citizenship are required. The person who signs the affidavit must provide proof of citizenship and identity. A person who is not related to the applicant or member must sign at least one of the affidavits.
	 (2) 	 When affidavits of citizenship are used, Form 470-4374 or 470-4374(S), Affidavit Concerning Documentation of Citizenship, or an equivalent affidavit explaining why other evidence of citizenship does not exist or cannot be obtained must also be submitted and must be signed by the applicant or member or by another knowledgeable person (guardian or representative).
	 75.11(3) Deeming of sponsor’s income and resources.
	  a.   	 In determining the eligibility and amount of benefits of an alien, the income and resources of the alien shall be deemed to include the following:
	 (1) 	 The income and resources of any person who executed an affidavit of support pursuant to Section 213A of the Immigration and Nationality Act (as implemented by the Personal Responsibility and Work Reconciliation Act of 1996) on behalf of the alien.
	 (2) 	 The income and resources of the spouse of the person who executed the affidavit of support.
	  b.   	 When an alien attains citizenship through naturalization pursuant to Chapter 2 of Title III of the Immigration and Nationality Act or has worked 40 qualifying quarters of coverage as defined in Title II of the Social Security Act or can be credited with qualifying quarters as defined at subrule 75.11(1) and, in the case of any qualifying quarter creditable for any period beginning after December 31, 1996, did not receive any federal means-tested public benefits, as defined in subrule 75.11(1), during any period, deeming of the sponsor’s income and resources no longer applies.
	 75.11(4) Eligibility for payment of emergency medical services. Aliens who do not meet the provisions of subrule 75.11(2) and who would otherwise qualify except for their alien status are eligible to receive Medicaid for care and services necessary for the treatment of an emergency medical condition as defined in subrule 75.11(1). To qualify for payment under this provision:
	  a.   	 The alien must meet all other eligibility criteria, including state residence requirements provided at rules 441—75.10(249A) and 441—75.53(249A), with the exception of rule 441—75.7(249A) and subrules 75.11(2) and 75.11(3).
	  b.   	 The medical provider who treated the emergency medical condition or the provider’s designee must submit verification of the existence of the emergency medical condition on either:
	 (1) 	 Form 470-4299, Verification of Emergency Health Care Services; or
	 (2) 	 A signed statement that contains the same information as requested by Form 470-4299.
This rule is intended to implement Iowa Code section 249A.3.