Presentation by Julia Paradise Principal Policy Analyst

1. 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

2. Citizenship Documentation in Medicaid:A 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

3. 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 don’t 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.

5. Acceptable Documentation under DRA 1) One of these: • U.S. Passport • Certificate of Naturalization • Certificate of U.S. Citizenship • Valid State-issued driver’s 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

6. 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.

8. HHS Interim Final Rule Major Provisions (3) • Data matching . DRA’s 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.

9. 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.

10. New York’s 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

11. 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.

12. 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

13. 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