DRA Evidence of Citizenship and Identity Requirements

1. DRA Evidence ofCitizenship and Identity Requirements Stan Rosenstein Deputy Director Medical Care Services

2. Federal Mandate • DRA requires Medicaid programs to verify citizenship and identity of people declaring they are citizens. • States lose federal funding if they do not comply. • Effective July 1, 2006. • Federal government will audit. • California is implementing as quickly as possible in a reasonable and responsible manner.

3. Federal Regulations:State Comments • California commented on the interim final regulations. • Unclear when or what changes will be made. • Implementation must occur with current regulations.

4. Federal Regulations:State Comments • Makes it more difficult for similarly situated U.S. citizens to receive healthcare services from Medicaid than for legal immigrants--applicants should be eligible during opportunity period. • Foster care children should be exempt. • Original or certified documents should not be required. • All deemed infants who are born in the U.S. should be considered citizens.

5. Federal Regulations: State Comments • The interim final regulations should not require persons providing an affidavit to prove citizenship and identity. • Allow discretion to determine whether the submitted documents, if not noted in the regulatory hierarchy, are of adequate reliability. • Regulations greatly underestimate the expenditure of time that the citizenship documentation requirements create. • The interim final regulations should allow states to verify citizenship of children born in the U.S. through provider claim records.

6. Experience in Other States • Hawaii reports 40% of returned packages do not have required documentation. • Virginia reports 10,000 applicant children so far not eligible--relying on documents. • Washington accepting copies of documents. • Illinois announces it will not deny eligibility due to a lack of documentation. • States all facing major implementation issues.

7. State Process • State law requires implementation. • Provide as much flexibility and time as federally allowed. • Implementation through an All County Letter. • Stakeholder and county input required. • Draft released for comment in July 2006.

8. State Process • The Department received over 500 comments from 50-60 stakeholders. • A revised draft of the All County Letter is currently in development and will be posted for final comments. • State must balance clear federal requirements tied to receipt of eligibility and federal funds with the need to reasonably and responsibly run the Medi-Cal program.

9. Evidence of Citizenship • Most Medi-Cal applicants and beneficiaries who declare that they are U.S. citizens or nationals must provide evidence of citizenship and identity as a condition of eligibility for Medi-Cal. • The evidence of citizenship/identity requirements do not apply to immigrants.

10. Evidence of Citizenship • The following groups are exempt from the evidence of citizenship requirements: • SSI beneficiaries. • Medicare beneficiaries. • Other possibilities: • Deemed eligible infants who are born in the U.S. and are citizens. • Minor consent applicants and beneficiaries. • Title IV-E Foster Care and Title IV-E Adoption Assistance children. • Infants under the Abandoned Baby Program who are born in the U.S. and have no documentation.

11. Demographics(Estimates based on January 2006 Data) • Total estimated Medi-Cal population 6.5 million • Total exempt due to Medicare coverage, SSI eligible, undocumented status, presumptive eligibility (*) 2.4 million • Total subject to verification 4.1 million • Total under 21 years old 3.0 million • Total over 21 years old 1.1 million (*) Legal immigrants not included. This will further reduce the number of people impacted. Those on presumptive eligibility will need to provide documentation after presumptive eligibility period ends.

12. Evidence of Citizenship • Documents must be original or certified copies. • Applicants must provide evidence of citizenship/identity before they can receive full scope Medi-Cal. • Beneficiaries must provide evidence at redetermination--remain eligible during process. • Reasonable opportunity period is not time limited-requires good faith.

13. Evidence of Citizenship • The Department has run vital records matches to identify Medi-Cal beneficiaries born in California. • When the State obtains a valid matching record, these beneficiaries will not have to provide evidence of citizenship, but will have to provide evidence of identity. • Counties can request a vital records match for new applicants and beneficiaries through the MEDS system. • Process key to avoiding problem similar to Virginia.

14. Evidence of Citizenship • The federal government has developed a list of acceptable documents including affidavits of U.S. citizenship/national status when no other evidence is available. • Rely on individual to decide which documents they have. • Affidavits of identity may be used for children under 16. California will accept a signed application that includes information about the place and date of birth as an affidavit of identity for children under 16. • Combine with birth certificate match.

15. Evidence of Citizenship ACWDL • Evidence of citizenship/identity is only required once. • Applicants and beneficiaries will be given a reasonable opportunity period to provide documents. California will define this period of time as broadly as is allowed by federal law.

16. Evidence of Citizenship • The reasonable opportunity period to provide documents will be extended for applicants or beneficiaries who are making a good faith effort to obtain documents. • Counties are required to assist applicants and beneficiaries who are unable to provide evidence of citizenship/identity. • Applicants or beneficiaries who stop making a good faith effort will be eligible for restricted Medi-Cal back to their original date of application if they are otherwise eligible.

17. Evidence of Citizenship ACWDL • The Department will implement a multifaceted outreach plan to notify and inform applicants and beneficiaries about the new requirements in several ways such as notices, fliers, posters, and mass mailings to current beneficiaries.

18. Stakeholder Comments • CDHS received comments from 50-60 organizations. • The list of acceptable documents is not exhaustive. • Provide immediate coverage to otherwise eligible citizens. • Provide full scope coverage to citizens who fail to provide evidence of citizenship but who are otherwise eligible for Medi-Cal.

19. Stakeholder Comments • Persons providing an affidavit on behalf of a Medi-Cal applicant or beneficiary should not be required to prove citizenship and identity. • Foster children and former foster children should be exempt. • Exempt deemed eligible Infants. • More specific information about how the requirement is applied to minor consent. • Define good faith effort as broadly as possible and provide examples of good faith effort.

20. Stakeholder Comments • Place more emphasis on who is not affected by the evidence of citizenship requirements such as immigrants and other exempted groups. • Persons other than eligibility workers should be allowed to accept evidence of citizenship. • Implement a process to track citizens who receive restricted Medi-Cal because they fail to meet the evidence of citizenship requirements. • The State should provide procedures to counties regarding collecting and returning original documents. • Expand the use of data matches.

21. Stakeholder Comments • Clarify on notices and materials that citizenship and identity requirements do not apply to persons that are not on Medi-Cal. • Re-determination packets should inform the beneficiary of a successful birth record match. • Notices must be translated into threshold languages and must be at an appropriate literacy level. • Targeted outreach to those who are required to provide documents. • Health plans need more information about the impact that evidence of citizenship will have on them.

22. Stakeholder Comments • Provide more guidance to the county on how to assist applicants and beneficiaries with meeting the evidence of citizenship and identity requirements and obtaining documentation. • The Department should pay the costs of obtaining the required documents or waive state fees for acceptable documents. • The All County Letter needs to address the requirements for retroactive eligibility. • The reasonable opportunity period needs further clarification. • Counties do not have adequate time to implement the evidence of citizenship and identity requirements.

23. Funding • Recognize that this change will increase county cost. • State budget provides ability to shift funds to reimburse counties for work. • We do not have an estimate of cost. • Plan to release draft letter and work with CWDA to develop cost estimate and provide funding.