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Medicaid Citizenship Documentation Requirements
Provisions and Implications of the Deficit
Reduction Act of 2005

• Presentation by
• Julia Paradise
• Principal Policy Analyst
• Kaiser Commission on Medicaid and the Uninsured
• for
• Grantmakers In Health
• July 18, 2006

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Citizenship Documentation in MedicaidA Brief
History

• Before February 8, 2006 Federal law requires
  Medicaid applicants to attest in writing that
  they are citizens, under penalty of perjury, but
  does not require documentation
• February 8, 2006 Deficit Reduction Act of 2005
  signed into law
• June 9, 2006 CMS Guidance published
• June 28, 2006 Federal class-action lawsuit
  filed
• July 1, 2006 Documentation requirement took
  effect
• July 6, 2006 Interim Final Rule with Comment
  Period released

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Medicaid Citizenship Requirements Before DRA

• U.S. citizenship or satisfactory immigration
  status is a condition of eligibility for
  Medicaid.
• All states but four (Georgia, New York, Montana,
  and New Hampshire) allow written
  self-declaration of citizenship.
• Most legal immigrants are excluded for Medicaid
  for their first 5 years in the U.S.
• Undocumented immigrants are not eligible for
  Medicaid except for emergency services.

4
DRA Mandate for Citizenship DocumentationMajor
Provisions of Section 6036

• Effective July 1, 2006, citizens applying for or
  renewing Medicaid coverage must provide
  documentation of U.S. citizenship and identity.
  Exemptions are included but dont make sense.
• No federal Medicaid matching funds are available
  for services provided to individuals who have
  declared but not documented their citizenship.
• Specifies satisfactory documentary evidence and
  authorizes Secretary to expand list of acceptable
  documents.
• Requires HHS Secretary to establish outreach
  program to provide education about the
  documentation requirements.

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Acceptable Documentation under DRA

• 1) One of these
• U.S. Passport
• Certificate of Naturalization
• Certificate of U.S. Citizenship
• Valid State-issued drivers license or identity
  document, but only if state requires proof of
  citizenship or obtains and verifies SSN before
  issuing
• OR
• 2) Both of these
• Birth certificate
• Personal identity document

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HHS Interim Final Rule Major Provisions (1)

• Requirement for FFP Effective July 1, 2006, to
  receive federal matching funds, States must
  obtain satisfactory documentation of citizenship
  and identity for all individuals who declare they
  are citizens.
• Exemptions Medicare and most SSI beneficiaries
  are exempt. No other groups are exempt (e.g.,
  foster children, newborns).
• Current enrollees vs. new applicants Enrollees
  must document citizenship at first
  redetermination after July 1, 2006. They have
  reasonable opportunity to provide evidence
  before state can terminate Medicaid eligibility.
  Applicants cannot obtain Medicaid benefits until
  they provide satisfactory evidence.

_________________________ HHS Interim Final Rule
with Comment Period, published and effective July
6, 2006.
7
HHS Interim Final Rule Major Provisions (2)

• Hierarchy of reliability Acceptable evidence is
  classified into primary, secondary, 3rd-level,
  and 4th-level tiers. States must seek
  highest-tier evidence available. All secondary
  and lower-tier evidence must be accompanied by
  identity document.

Primary U.S. Passport, Certificate of Naturalization, Certificate of U.S. Citizenship, or, subject to certain conditions, a state-issued drivers license SDX match for SSI beneficiaries.
Secondary Birth certificate (or data match) or specified other record (e.g., final adoption decree, U.S. military record).
3rd Level Hospital record, or life, health, or other insurance record.
4th Level Many non-governmental documents (e.g., census record, provider admission or medical record). Written affidavit permitted as last resort, under rigorous conditions.
Identity Diversity of photo IDs and other military, Tribal, and school IDs and records data cross-matches to federal and state agencies.
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HHS Interim Final Rule Major Provisions (3)

• Data matching . DRAs acceptable evidence is
  expanded to include data cross-matches as well as
  additional documents.
• No copies Only original documents or copies
  issued by certifying agency are acceptable.
  States must retain copies in case record or
  electronic data base and make available for
  audit.
• Presumptive eligibility States that provide
  presumptive eligibility may continue to do so and
  receive FFP.
• State assistance States must assist 1)
  enrollees who make good faith effort but cannot
  secure evidence within reasonable opportunity
  period because it is not available, and 2)
  individuals who cannot comply because of mental
  or physical disability and have no one to assist
  them.

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HHS Interim Final Rule Major Provisions (4)

• Compliance CMS will monitor to ensure states
  have effective process for complying, and will
  monitor extent to which states use primary
  evidence and require corrective action to ensure
  they routinely obtain the most reliable evidence.
  
• Funding FFP at 50 match rate for Medicaid
  administrative costs.
• Comment period Interested parties have 30 days
  from date of publication in Federal Register to
  submit comments on the rule, by mail or
  electronically.

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New Yorks Medicaid Citizenship Documentation
Process Elements of Success

• Diverse array of acceptable documents (e.g.,
  baptismal record, family bible record)
• Primary evidence includes birth certificate
• Requires one form of primary or two forms of
• secondary documentation no hierarchical
  procedure
• Electronic data matches enable NY to provide
  Medicaid automatically to individuals deemed
  eligible for TANF, SSI, or Title IV-E foster care
  payments. State also provides automatic
  eligibility for newborns of mothers receiving
  Medicaid
• Copies of documents permitted
• Substantial state funds and effort devoted to
  application assistance, including document fees

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Key Issues for Medicaid Applicants and
Beneficiaries

• Most Medicaid applicants and beneficiaries lack
  access to other health coverage.
• Many low-income people do not have the required
  documents or face financial and other barriers to
  obtaining them.
• Research shows that documentation requirements
  and in-person application processes depress
  participation in assistance programs.
• Lack of outreach means Medicaid population is
  unlikely to know about this new requirement.
• State use of authority to conduct data
  cross-matches to other agencies and programs
  could minimize documentation barriers for
  Medicaid applicants and beneficiaries.

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Key Issues for States

• States will need additional state resources to
  implement the federal mandate for systems,
  outreach, staff
• States face a major outreach challenge for a new
  requirement that is already in effect
• Authority to use data matches instead of
  collecting documents could mitigate impact on
  state efforts to streamline Medicaid enrollment
  and automate.
• Little time for implementation (e.g., systems
  development, hiring, training, outreach, state
  legislative change)
• Potential increases in uninsured and increased
  pressures on safety net providers

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Opportunities for Funders

• Research
• Tracking and surveillance
• caseload-related
• state operational choices
• Surveys, focus group and case studies,
  longitudinal studies to describe and evaluate
  impact of the citizenship documentation
  requirement on
• individuals application and enrollment
  experience, including time and document costs,
  and coverage delays and denials
• particular subgroups (e.g., foster children,
  newborns of immigrants, people with disabilities
  not on SSI)
• safety-net providers
• Profiles of best state practices
• Direct assistance
• Outreach to Medicaid population
• Assistance in obtaining documents
• Financial assistance with document fees