CLTS FS Instructions Module #2: Informational Pages

Contents

2.1 Identifying Information
2.2 Screen Types
2.3 Screen Dates
2.4 Screen Information
2.5 Child's Information  
2.6 Living Situation 
2.7 Legal Concerns
2.8 U.S. Citizenship and Identity | Acceptable Citizenship and ID Documentation
2.9 Ethnicity & Race Information
2.10 Interpreter Language Required
2.11 Contact Information 


2.1 Identifying Information

When searching for a child or entering the information for a New Applicant into the CLTS FS, the child's name, date of birth and Social Security Number are critical items for identification. They must be entered accurately. If a child is not a client in the CLTS FS and the screener must add them as a New Applicant, the system will check other databases to see if the child exists in other systems in order to link data for accuracy. If the system identifies some or all of this identifying information for a child, it will report back optional clients to select in order to proceed. If one of those clients matches the child the screener is entering as a New Applicant, especially if there is a 90% or better match of this identifying information, the screener should select that client and proceed.

The identifying information is initially entered when adding a client to the system. It is updated or changed on the Individual Information page. If there is an error, or a screener needs further assistance with this process, contact the DHS SOS Help Desk. The DHS SOS Help desk's email is: DHSSOSHelp@wisconsin.gov.

Name
If the child has a "Jr." or "IV", or other suffix added to their name, list this in the Last Name box, following their last name.

Name Change / Name Misspelled
If the child's name has changed, often due to an adoption, or a screener notices that the name has been misspelled on the screen, the name can be changed on the CLTS FS. Select the screen with the child's previous name and update the information contained on the Individual Information page of the screen. This updated information will be saved for future screens but the information will not affect previously calculated screens.

Date of Birth
Enter the child's date of birth in MM/DD/YYYY format, as in 01/01/2011. A calendar option is available to improve accuracy. CLTS FS programming will not allow dates to be entered that make the applicant more than 22 years old. The person should be referred for an adult screen in this instance. The date of birth must be earlier than the Screen Begin date.

Social Security Number
Enter the child's Social Security Number (SSN) in the ###-##-#### format. Only enter the SSN as it appears on the government issued Social Security Card in the child's name.

Pseudo Social Security Number
The only time a certified screener should select to use a Pseudo Social Security Number (SSN) is when the child does not have an actual SSN issued at the time of the home visit (e.g., newborn infants). Do not use a Pseudo SSN simply to enter a screen prior to learning the child's actual SSN.

When a Pseudo SSN is used, the child's identifying information does not go through the MCI clearance. Therefore, if you have a SSN but question the accuracy of it, use the SSN provided to you and then the MCI can check to see if it is a match to another SSN listed for the child.

If a previous screener used a Pseudo SSN and you now have the child's actual SSN, please make the necessary correction in two places. First, uncheck the Pseudo SSN box on the Individual Information page and then enter the correct SSN on that page.

SSN Status
The child's SSN Status displays the system's understanding of the information entered in the Social Security Number field. If the child is already known to the system, their status will read "Verified SSN". If it is a new SSN, the status will initially be "Unverified SSN". It typically takes the system 7-10 days to verify a child's social security number. Other possible options are indications of a miss-match of information involving the child's name, date of birth and SSN.

Social Security Number Entered Incorrectly
When a screener identifies that a social security number has been entered incorrectly, the error must be corrected internally. Contact the DHS SOS Help desk with the child's full name, incorrect social security number and correct social security number. The DHS SOS Help desk's email is: DHSSOSHelp@wisconsin.gov. This is a very costly error and should be avoided.

Duplicated Screens
If there is more than one functional screen for the same child, the additional screens can only be merged together through support from the DHS SOS Help desk. This is a very costly and manual process and should be avoided. The screen to use, when multiple screens are available for one child, is the screen with the child's correct social security number. The screen with a pseudo or incorrect social security number should be the one that is deleted. Contact the DHS SOS Help desk with the child's full name, incorrect screen identification and correct screen identification. The DHS SOS Help desk's email is: DHSSOSHelp@wisconsin.gov.

Master Customer Index Identification Number (MCI ID)
The Master Customer Index (MCI) identification number is another form of identification for a child. It will appear on the Individual Information page next to the child's date of birth. This number is generated by the greater system. It is often, but not always, the child's Medicaid ID number.

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2.2 Screen Types

The screener will select one option whenever they complete a CLTS FS. There are two screen types from which to choose: Initial and Rescreen. The screen type relates to the reason or place a child is at regarding their relationship to a specific program for which the CLTS FS determines functional eligibility.

INITIAL SCREEN
The first CLTS FS completed for a child interested in accessing long-term support services is an Initial Screen. Initial Screen is also selected when a child has been enrolled in one program but is now initially applying for a different program. Likewise, if a child is on a waiting list and is now being screened for services or enrollment, an Initial Screen is selected and completed.

An Initial Screen is selected in the following four circumstances:

  1. The very first time a screen is created for a new applicant. No previous screen exists for the child.
  2. A child has a completed screen for one program but now is having their first screen completed for a different program.
  3. A child has been on a waiting list for a particular program and is now coming off the waiting list for service delivery.
  4. Any time a child was discontinued from a program or found Not Functionally Eligible for services and is now reapplying for the same program.

RESCREEN
A Rescreen or recertification screen is required as long as a child is enrolled in a long term support program. This type of screen is usually required annually. Rescreen is also used when a screener wants to accept the information entered by a previous screener and work off of that screen for their screening purposes.

EDIT
A screener may use Edit to add or change information in a screen that they are currently working on. After six months has past, a screener must select Rescreen rather than continuing to use Edit to access the screen.

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2.3 Screen Dates

Referral Date
The Referral Date is the date the screener received the initial request for service from a parent/guardian or another referral source.

Screen Begin Date
The Screen Begin Date is the date of the screener's first face-to-face contact with the child and parent(s).

The Referral Date and Screen Begin Date may be used to assess state and local systems for timely responses to families' requests for screening. The difference between the Referral Date and the Screen Begin Date will be tracked as part of quality improvements to ensure timely responses to requests for screening. This is quality improvement for systems, not individual screeners. For instance, if one county always takes, on average, three weeks longer than other counties, there may be local systems changes they can make to improve their response time. A Referral Date is only required on Initial Screens.

Screen Completion Date
The screener enters the Screen Completion Date as the date that they have entered all the required information into the CLTS FS and are prepared to calculate eligibility. The Screen Completion Date is recorded on the last page of the CLTS FS.

Screen "Determined On" Date
This is a system generated date that will report the actual date eligibility was calculated on the screen.

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2.4 Screen Information

Screener's Name
The screener's name must be selected from the drop down box available on the screen. By selecting the screener's name, the email on file will be automatically displayed.

Referral Source
Select from the drop down box to indicate who contacted the screening agency to refer this person for a screen. The CLTS FS is designed to determine functional eligibility for children; therefore, we are seeking the referral source that recommended that the family contact the screener agency. Use parent as the referral source only if no other person prompted them to contact the screener. If another parent provided the referral to this family, then it is also appropriate to select "parent" from the drop-down options. A referral source is only required on Initial Screens.

Is this functional screen being completed for the purpose of determining Level of Care for a CLTS Waiver? Answer "No" if a child is enrolled in a CLTS Waiver.
This question distinguishes screens completed for application to state funded Children's Waivers versus those completed for other programs or for children already on a CLTS Medicaid Waiver. This is an important differentiation for purposes of reporting to CMS, Centers for Medicare and Medicaid Services.

If this functional screen is being completed for a child applying for a state funded CLTS Medicaid Waiver (PD, DD or MH), then answer this question “Yes”. If this screen is being completed to move a child off of a waiting list and on to the CLTS Waiver, screeners will answer this question "Yes". If a child is receiving CLTS Waiver services, and the screen is being completed as part of the ongoing recertification process, then this question is answered “No”. If the screen is being completed for any other program, this question is answered “No”.

For which of the following programs is this Functional Screen being completed? (Check all that apply at this time)

  • Comprehensive Community Service
  • Community Recovery Services
  • Community Options Program
  • Family Support Program
  • Children's Long Term Support Waiver
  • Katie Beckett Medicaid Program
  • Mental Health Wrap Around

In order to accurately track screen quality by programs, this question provides an opportunity to indicate for which program(s) the screen is being completed. A child may apply for one program or multiple programs at a time. Once a child is receiving services through a program, the screener will only select that program when completing an annual Rescreen.

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2.5 Child's Information

Address
Enter the child's "permanent residence" address. For transient persons, enter the address they lived at the most in the last six months.

If there is a street address and a PO Box, enter street address and apartment information on line 1, PO Box on line 2, and use the PO Box ZIP Code.

County/Tribe of Residence and County/Tribe of Responsibility
Select the appropriate county/tribe from the drop down box. Typically these will be the same entry. However, in a few instances, people may live in one county but another county/tribe is responsible for services, costs, and/or protective services. For the purposes of screening, residency is physical presence or the intent to reside. The CLTS FS program will automatically enter county of responsibility to be the same as county of residence. This "default" entry can be overridden if different counties are involved.

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2.6 Living Situation

Current Residence of the Child:
Select the appropriate response from the drop down box. If the screener selects "other," type an explanation in the "other" box. Most of the drop down box menu options are self-explanatory.

If a family is homeless but the child is under 18 years old and living with their parents, please select "with parents" for their living situation. If they are over 18 years old and homeless, then select "no permanent residence."

If a child is living in a kinship care arrangement, select "with other unpaid family members."

Number of residents (# of beds) certified for?
If a child lives in a multiple bed complex, indicate the number of beds for the license. This applies to the following living situations: Foster Care or Other Paid Caregiver's home; Treatment Foster Home; Children's Group Foster Home; Adult Family Home; Community Based Residential Facility.

If a child is in an out of home placement, answer the question, "Is the child expected to return home within 6 months of screening date?"

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2.7 Legal Concerns

Are the child's parents aware of the legal concerns (e.g. Guardianship, Power of Attorney, and Representative Payee) once the child turns 18 years old?
This is a required field once the child is 16 years of age. It is not necessary to know the family's specific choice when the child reaches 18 years of age, since the intent of the question is whether or not they are considering the issues involved as their child becomes an adult.

Is the child, who is 18 years of age or older, their own guardian (i.e., s/he does not have a legal guardian)?
This is a required field once the child is 18 years of age. If the young adult does not require guardianship of person, they are considered a competent adult.

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2.8 U.S. Citizenship and Identity

Per Federal regulations, United States citizenship and personal identity must be verified for any child seeking Wisconsin Medicaid eligibility which includes Medicaid funded Waiver services. The CLTS FS has required fields where the screener records the documentation viewed to verify both the child's U.S. citizenship and personal identity.

The U.S. citizenship and personal identity requirement applies to all children applying for or receiving services from a Medicaid funded program which includes the Katie Beckett Program and the Children's Long-Term Support Waivers. The Family Support Program (FSP), Community Options Program (COP) and MH Wrap Around programs do not require citizenship and identity documentation. The Comprehensive Community Services (CCS) program requires participants to be Medicaid recipients prior to service provision so United States citizenship and personal identity will have already been verified through their application to Medicaid.

For more information regarding these procedures, refer to DHS Operational Memo 07-69 Citizenship and Identification Requirements Final Rule Summary (PDF) and the Acceptable Citizenship and ID Documentation list located at the end of this Module.

Screeners must refer to this memo and related charts for clarification on specific, acceptable documentation. In addition, each program for which the CLTS FS determines functional eligibility must adhere to its own citizenship and identity regulations.

For U.S. Citizenship, the screen asks the following questions:

  • Child has documentation to establish U.S. Citizenship. The certified screener will be required to indicate from a drop down menu what documentation was used to verify U.S. Citizenship.

  • Child does not have U.S. Citizenship but does have the following Alien Registration Number per the verified Permanent Resident Card. The certified screener will be required to enter the 9-digit Alien Registration number. For cases with a 9-digit A number, all digits must be provided. For cases with an 8-digit A number, a zero (0) must be inserted before the 8 digits.

  • Child claims to have U.S. Citizenship or an Alien Registration Number but required documentation was not provided. The certified screener will be responsible for updating this screen once the documentation is available.

  • Child is only seeking eligibility for the Family Support Program, Community Options Program, Comprehensive Community Services, and/or Mental Health Wrap Around Program.

Note that these options are mutually exclusive, that is, only one can be selected. As a result, if a screener is entering a screen where the first item (Child has documentation to establish U.S. Citizenship) has already been selected in the past, it should remain checked even if the current program they are applying for does not require U.S. Citizenship. For example, if a child has previously applied for Katie Beckett Program - Medicaid which requires U.S. Citizenship and the Katie Beckett Program certified screener selected the first option above and then the child applies for the Family Support Program (which does not require U.S. Citizenship), the Family Support Program certified screener should leave the first option selected to not negatively affect the child's eligibility for the Medicaid funded program.

If a Permanent Resident Card and/or Alien Registration Number is the documentation being used for Medicaid eligibility this requires further review. This review of Medicaid eligibility can only be done by a Nurse Consultant for the Katie Beckett Program or by a county Economic Support Unit (ESU) for all other Medicaid programs, such as the CLTS Waivers. Therefore, either the Nurse Consultant's name or the Economic Support Worker's name, plus the date this required eligibility was verified, must also be documented in the final notes section of the CLTS FS.

If the child is seeking a Medicaid funded program (Katie Beckett Program or CLTS Waiver) and the screener does not have documentation of U.S. Citizenship, the following warning will be posted:

  • U.S. Citizenship: You've checked that the child claims to have U.S. Citizenship or an Alien Registration Number but required documentation was not provided. It is your responsibility as a certified screener to change the U.S. Citizenship verification on the functional screen when the required documentation is obtained. If a child is awarded eligibility for a program without the required verification of documentation, your agency is at full risk for the full cost of services for this child without any federal matching funds.

The screen will also have the following pending results:

  • Not eligible due to lack of U.S. Citizenship documentation and verification. Services cannot be provided through this program without required documentation.

"Pending documentation" is available as an option under Identity and can be used when a screener has requested the necessary documentation but has not yet received it. The functional eligibility results will continue to indicate that verification is required.

"Not a Medicaid funded program" is available as an option under Identity. When a screener is completing a screen for The Family Support Program (FSP), Community Options Program (COP), MH Wrap Around or Comprehensive Community Services (CCS) they may select this option. If a screener completes a CLTS FS for a child who already has their identity verified by a previous screener, please do not change that information to "Not a Medicaid funded program", even if the program you are completing a screen for does not require the verification.

Once a child's U.S. citizenship and personal identity has been verified by the proper documentation, it does not need to be verified annually at recertification.

If screeners have further questions regarding verification of U.S. citizenship or personal identity requirements, please contact the Children's Services Specialist for your county or your specific program manager.

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2.9 Ethnicity & Race Information

ETHNICITY
This is not a required field. If needed, use the following definition to identify the appropriate option:

  • Hispanic / Latino: A person of Mexican, Puerto Rican, Cuban, Central, South American, or other Spanish culture or origin, regardless of race.

RACE
This is not a required field. Please check all boxes that apply. The choices here match federal insurance reporting requirements. If needed, use the following definitions to identify the appropriate option:

  • American Indian or Alaska Native: "American Indian and Alaska Native" refers to people having origins in any of the original people of North and South America (including Central America), and who maintain tribal affiliation or community attachment. It includes people who indicate their race or races as Rosebud Sioux, Chippewa, or Navajo.

  • Asian: Refers to people having origins in any of the original peoples of the Far East, Southeast Asian, or the Indian subcontinent. It includes people who indicate their race or races as "Asian Indian," "Chinese," "Filipino," "Korean," "Japanese," "Vietnamese," or "Other Asian," or as Burmese, Hmong, Pakistani, or Thai.

  • Black or African American: "Black" refers to people having origins in any of the Black racial groups of Africa. It includes people who indicate their race as "Black," African American, Afro-American, Nigerian, or Haitian.

  • Native Hawaiian or Other Pacific Islander: "Pacific Islander" refers to people having origins in any of the original peoples of Guam, Samoa, or other Pacific Islands. It includes people who indicate their race or races as "Native Hawaiian," "Guamanian or Chamorro," "Samoan," or "Other Pacific Islander," or as Tahitian, Mariana Islander, or Chuukese.

  • White: "White" refers to people having origins in any of the original peoples of Europe, the Middle East, or North Africa. It includes people who indicate their race as "White" or as Irish, German, Italian, Lebanese, Near Easterner, Arab, or Polish.

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2.10 Interpreter Language Required

Leave this blank if no interpreter is needed. Select the appropriate language if an interpreter is needed. If "Other," please type in the language needed in the space provided. Human service and health care providers should always obtain interpreters when they are needed. This information will help show the extent of such needs, and will also help long-term care programs better serve people whose primary language is not English.

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2.11 Contact Information

Contact Information
For children under age 18, at least one "Contact" must be entered who has legal rights to the child's records. For applicants 18 or over, if they are not their own legal guardian, then at least one "Contact" must be entered who has legal rights to the child's record.

Parents must be entered separately as two different contacts. DHS correspondence will be sent to the first Contact listed.

In cases of joint custody in which one parent does not reside with the child, that parent’s contact information must be included. If the second parent does not have joint custody, this information is optional.

For convenience, the child’s address and home telephone number will auto-fill if the screener selects "parent" as the type of contact. The screener can delete or write over this information if it is not correct for the contacts. If a contact person’s name is not clearly gendered, the screener can note the person’s gender in the Notes section for future reference.

If there is a street address and a PO Box, enter street address and apartment information on line 1, PO Box on line 2, and use the PO Box ZIP Code.

The home telephone number is a required field. If the person has no telephone enter all "zeros" (000) 000-0000.

If a contact person does not have a known address, put the person's name and any additional information the screener has in the note section on this page.

Has legal rights to child's record
For each contact listed, check this box if the contact has legal rights to the child's records. This will typically be the child's biological or adoptive parent(s) or guardian.

DELETE / ADD NEW
For any contact previously listed on a screen that is no longer an appropriate contact for the child, the screener can select the Delete button and that entire contact will be deleted. To add additional contacts, use the Add New button located towards the bottom of the page.

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ACCEPTABLE CITIZENSHIP AND ID DOCUMENTATION

  • Level 1: Documentation documents both citizenship and identity.
  • Levels 2, 3 and 4: Documentation documents only citizenship. It must be presented with documentation of identity (level 5).
  • Levels 5: Documentation documents only identity. It must be presented with documentation of citizenship (levels 2, 3 or 4).
  • Level 7: Documentation can be used to meet Citizenship or Identity.

Level 1 Documentation of Citizenship and Identity

Doc Level Acceptable Documentation Valid CARES Code Description/Explanation
1 U.S. Passport PP The Department of State issues this. A U.S. passport does not have to be currently valid to be accepted as evidence of U.S. citizenship, as long as it was originally issued without limitation. Do not accept any passport as evidence of U.S. citizenship when it was issued with a limitation. Passports issued with a limitation may only be used as proof of identity.
1 Certificate of Naturalization CI Form N-550 or N-570. Issued by the Department of Homeland Security for naturalization.
1 Certificate of Citizenship CI Form N-560 or N-561. The Department of Homeland Security issues certificates of citizenship to individuals who derive citizenship through a parent.
1 State Data Exchange (SDX) SC The State has conducted a data match between SDX and individuals known to CARES, updating the citizenship verification field with the code “SC” whenever SDX indicated that an individual’s U.S. citizenship had been confirmed for SSI or Medicare purposes. SDX is considered primary evidence of U.S. citizenship, so individuals whose citizenship verification field contains SC are considered to have met both the citizenship and the identification documentation requirement. No further documentation should be required of such individuals.
1 SSI-Medicaid/
BadgerCare Plus Recipient
Medicare Recipient
SSDI Recipient
SC Use the SC code when updating SSI-MA Medical Assistance, SSDI and Medicare recipient records via the SDX indicator of citizenship. Verify the receipt of these benefits by completing an online query (SOLQ) of DXSX for SSI and DXSA for Medicare and SSDI. To confirm SSDI receipt on DXSA, the person must be in current pay status on their own account and under age 62. The SSA claim number is the person’s SSN and the BIC is “A.”

Individuals receiving SSI-MA Medical Assistance, SSDI or Medicare are exempt from this policy and should not be asked to provide citizenship or identity documentation.

1 Individual is a Continuously Eligible Newborn (CEN) NB Use the NB code when a CEN is being added to a case. Citizenship and identity verification is not required for CEN individuals until the next review is done. This code will automatically be removed from the fields at review or intake so that a valid code can be entered at that time.

Levels 2-4 Documentation of Citizenship Only

Doc Level Acceptable Documentation Valid CARES Code Description/Explanation
2 Birth Certificate BC

BQ

A U.S. public birth certificate showing birth in one of the 50 States, the District of Columbia, Puerto Rico (if born on or after January 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (on or after January 17, 1917), American Samoa, Swain’s Island, or the Northern Mariana Islands (after November 4, 1986). The birth record document may be recorded (previously ‘issued’) by the State, Commonwealth, Territory or local jurisdiction. It must been created/recorded before the person was 5 years of age. A delayed (previously ‘amended’) birth record document that is amended after 5 years of age is considered fourth level evidence of citizenship.”

Use BQ if a birth record query is done.

Note: Effective 10/01/10, all Puerto Rican Birth Certificates issued before 07/01/10 are invalid. Ongoing recipients of IM programs from Puerto Rico do not need to submit new, valid birth certificates. However, all Puerto Rican Birth Certificates submitted by applicants must have been issued after 07/01/10.

2 Certification of Report of Birth SD The Department of State issues a DS-1350 to U.S. citizens in the U.S. who were born outside the U.S. and acquired U.S. citizenship at birth.
2 Consular Report of Birth Abroad of a US Citizen SD Form FS -240. The Department of State consular office prepares and issues this. Children born outside the U.S. to U.S. military personnel usually have one of these.
2 Certification of Birth Abroad SD Form FS -545. Issued by the Department of State consulates prior to November 1, 1990.
2 US Citizen ID Card, American Indian Card, or Northern Mariana Card CD US Citizen ID Card
The Immigration and Naturalization Service (INS) issued the I-179 and the I-197 from 1960 until 1983 to naturalized U.S. citizens living near the Canadian or Mexican border who needed it for frequent border crossings.

American Indian Card
Form I-872. DHS issues this card to identify a member of the Texas Band of Kickapoo living near the U.S./Mexican border. A classification code of “KIC” and a statement on the back denote U.S. citizenship.

Northern Mariana Card
Form I-873. Issued by INS for those born in the Northern Mariana Islands before 11-4-86.

2 Final Adoption Decree AD The adoption decree must show the child’s name and U.S. place of birth. Where an adoption is not finalized and the state in which the child was born will not release a birth certificate prior to final adoption, a statement from a state approved adoption agency that shows the child’s name and U.S. place of birth is acceptable. The adoption agency must state in the certification that the source of the place of birth information is an original birth certificate.
2 Evidence of civil service employment by U.S. government ER The document must show employment by the U.S. government before 6-1-76. Persons employed with the U.S. Government prior to that date had to be U.S. citizens.
2 Official Military record of service MS The document must show a U.S. place of birth.
2 Medicaid Birth Claim MB When the WI Medicaid program pays the costs associated with the birth of an infant, the infant will be considered a U.S. citizen who has met the citizenship documentation requirement. Because this is level two evidence of citizenship, the identity documentation requirement must still be met. This code was used by the Department of Health Services, when the appropriate automated data matching was done.

This code can also be entered by workers when presented with the appropriate documentation.

2 Individual who previously received assistance through Foster Care, Adoption Assistance or Katie Beckett OP Use this code when you are aware that an individual who previously received assistance through the Foster Care, Adoption Assistance or the Katie Beckett program, has provided proof of their citizenship or identification through that program.
2 SAVE database SV Use this code when using the SAVE system to verify citizenship status for non citizens who gained US citizenship.
2 Acquired citizenship through parent(s) as outlined in the Child Citizenship Act 2000 (CCA) CA IM workers can use this code when an individual demonstrates that s/he has gained his/her US Citizenship through the CCA.
3 Hospital record HR Extract of a hospital record on hospital letterhead established at the time of the person’s birth that was created 5 years before the initial application date and that indicates a U.S. place of birth. Do not accept a souvenir “birth certificate” issued by the hospital. Note: For children under 16 the document must have been created near the time of birth or 5 years before the date of application.
3 Life, health or other insurance record IP Must show a U.S. place of birth and have been created at least 5 years before the initial application date.
3 School Record ED The school record must show a US birthplace, name of child, date of birth, date of admission to school, and name and place of birth of the applicant’s parents.
3 Religious Record or Baptismal Certificate RR An official religious record that is filed with a religious organization within 3 months of the birth. The document must show a US birthplace and either the date of birth or the individual’s age at time the record was made.
4 State or Federal census record CE Must show birthplace, citizenship & age. Census records from 1900 through 1950 contain certain citizenship information. To secure this information the applicant, recipient or State should complete a Form BC-600, Application for Search of Census Records for Proof of Age. Add in the remarks portion “U.S. citizenship data requested.” Also add that the purpose is for Medicaid eligibility. This form requires a fee.
4 Seneca Indian Tribal census record or Bureau of Indian Affairs census records of the Navaho Indians SN Must show U.S. birthplace and have been created at least 5 years before the application for Medicaid.
4 Bureau of Indian Affairs Roll of Alaska Natives IA Must show U.S. birthplace and have been created at least 5 years before the application for Medicaid.
4 U.S. State Vital Statistics official notification of birth registration VS Must show a U.S. birthplace and have been created at least 5 years before the application for Medicaid.
4 U.S. birth record amended more than 5 yrs. after person’s birth BR Must show a U.S. birthplace and have been created at least 5 years before the application for Medicaid.
4 Signed statement by physician or midwife in attendance at birth DS Must show a U.S. birthplace and have been created at least 5 years before the application for Medicaid.
4 Admission papers from nursing home, skilled nursing care facility or other institution NH Must show a U.S. birthplace and have been created at least 5 years before the application for Medicaid/BadgerCare Plus.
4 Medical record (doctor, clinic, hospital) MD Must show a U.S. birthplace and have been created at least 5 years before the application for Medicaid. An immunization record is not considered a medical record for purposes of establishing U.S. citizenship. Note: For children under 16 the document must have been created near the time of birth or 5 years before the date of application.
4 Written Affidavit WA Used only in rare circumstances. If the documentation requirement needs to be met through affidavits, the following rules apply:
  1. There must be at least two affidavits by two individuals who have personal knowledge of the event(s) establishing the applicant’s or recipient’s claim of citizenship (the two affidavits could be combined in a joint affidavit).
  2. At least one of the individuals making the affidavit cannot be related to the applicant or recipient. Neither of the two individuals can be the applicant or recipient.
  3. In order for the affidavit to be acceptable the persons making them must be able to provide proof of their own citizenship and identity.
  4. If the individual(s) making the affidavit has (have) information which explains why documentary evidence establishing the applicant’s claim or citizenship does not exist or cannot be readily obtained, the affidavit should contain this information as well.
  5. The State must obtain a separate affidavit from the applicant/recipient or other knowledgeable individual guardian or representative, explaining why the evidence does not exist or cannot be obtained.
  6. The affidavits must be signed under penalty of perjury.

Level 5 Documentation of Identity Only

Doc Level Acceptable Documentation Valid CARES Code Description/Explanation
5 State or Territory Driver license DR Driver license issued by a state or territory either with a photograph of the individual or other identifying information of the individual such as name, age, sex, race, height, weight or eye color.
5 School Identification card SI School identification card must have a photograph of the individual.
5 School Records ED When using other school records such as a report card, daycare or nursery school record, the document must be verified with the issuing school.
5 Written Affidavit (Form F 10154) SW An Affidavit of identity is only acceptable for children under 18 years of age. An affidavit is only acceptable if it is signed under penalty of perjury by a parent, guardian or caretaker relative stating the date and place of birth of the child and cannot be used if an affidavit for citizenship was provided. The parent or guardian does not have to declare their citizenship in this affidavit.

Use this code if presented with the Statement of Identity for Children Under 18 Years of Age (Form F 10154).

This affidavit can be used for children under age 18 when they have nothing else. The identity affidavit (F10154) is not required to be notarized.

5 Certificate of degree of Indian blood or other U.S. American Indian or Alaska Native tribal document TR Acceptable if the document carries a photograph of the applicant or recipient, or has other personal identifying information relating to the individual.
5 Native American Tribal document TR Must have a photograph or other personally identifying information that relates to the person named on the document.
5 Multiple Identity documents OI An individual may provide 3 or more corroborating ID documents to verify his/her identity.
5 U.S. Military card or draft record, Military dependent’s identification card, or US Coast Guard Merchant Mariner card MI Must show identifying information that relates to the person named on the document.
5 Identification card issued by Federal, State, or local government GI Must have the same information as is included on driver license.
5 FoodShare Identification Requirement met FS Verifying the identity of the primary person is a requirement for a FoodShare application. Once this requirement is met for FS, it is also met for the new identity verification requirement for Medicaid/BadgerCare Plus. The new <FS> code will be entered by CARES when there is a request for FoodShare and a valid FS verification code for identity is entered in the existing verification code field. When a valid verification code is entered, <FS> will automatically populate in the new Medicaid/BadgerCare Plus verification code field for the Primary Person. <FS> remains a valid Medicaid/BadgerCare Plus verification code for the primary person even if the individual is not currently eligible for FoodShare benefits.
5 Individual who previously received assistance through Foster Care, Adoption Assistance or Katie Beckett OP Use this code when you are aware that an individual who previously received assistance through the Foster Care, Adoption Assistance or the Katie Beckett program has provided proof of their citizenship or identification through that program.
5 Individual is a Continuously Eligible Newborn (CEN) NB Use the NB code when a CEN is being added to a case. Citizenship and identity verification is not required for CEN individuals until the next review is done. This code will automatically be removed from the fields at review or intake so that a valid code can be entered at that time.
5 Medical record MR Clinic, doctor or hospital record.
5 Institutional Care Affidavit IC A signed F 10175 can also be used when a residential care facility administrator attests to the identity of a disabled individual in the facility.
5 Motor Vehicle Data Exchange MV This code will appear in the identity verification field as a result of a data exchange update with the Division of Motor Vehicles.

This can also be used when verifying an individual’s identity through the DOT Driver License Status Check website.

If an applicant requests a backdate for Medicaid/BadgerCare Plus, and BEM updated the case with an <MV> code on 5/7/07, CARES will not recognize the <MV> as a valid code for those backdate months. Because the DMV data exchange is valid identity verification, the worker will need to enter <DR> for any backdate months where an <MV> code was updated.

Level 7 Documentation of Citizenship or Identity

Doc Level Acceptable Documentation Valid CARES Code Description/Explanation
7 Other appropriate documents for Special Populations F10161 W7 Other documents besides those listed in Levels 1-6 can be used to meet the requirement as long as the document meets the general documentation requirement stated here:

“Any document used to establish U.S. citizenship must show either a birthplace in the U.S. or that the person is otherwise a U.S. citizen. Any document used to establish identity must show identifying information that relates to the person named on the document.”

A signed F10161 can only be use for individuals who meet the definition of “Special Populations” and who are unable to obtain any level of acceptable documentation.

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Last Revised: July 21, 2014
Wisconsin Department of Health Services
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