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Kaiser Study Urges Delay of Medicaid Citizenship Documentation Rules

JUNE 23, 2006 -- A study by the Kaiser Family Foundation urges a delay in the July 1 start of new requirements specifying how states document the citizenship of Medicaid enrollees. The study said states face an "enormous job" carrying out the requirements, which critics say could cause many thousands of the nation's 55 million Medicaid beneficiaries to lose their coverage.

Even New York, pointed to by the federal Medicaid program in a June 9 letter as an example of the feasibility of documenting citizenship "without undue hardship to either applicants or the state," would face much difficulty complying if the requirements aren't modified, the study reported.

But a spokeswoman for the Centers for Medicare and Medicaid Services (CMS) said Friday that the Deficit Reduction Act (PL 109-171), which mandates the new documentation requirements, "was signed on Feb. 8 and was virtually self-implementing." States "have had several months to prepare," said spokeswoman Mary Kahn. "The statute is very straightforward about what documents are required."

A CMS "interim guidance document," released three weeks before the requirements go into effect explains how applicants must document both citizenship and identity. A final version of the document may be released by July 1.

The requirements will also apply to current Medicaid beneficiaries when they renew their coverage, which they must do at least once a year. Citizenship only needs to be established once, however.

Medicaid officials in both California and Ohio have said they won't be ready to enforce the rules July 1, according to published reports. But Kahn said Friday that "if they don't comply, the states are at risk of losing federal financial participation"—Medicaid's term for federal payments to the states to match their own Medicaid outlays.

Medicaid has long required states to establish that applicants are U.S. citizens, but only New York, Georgia, Montana, and New Hampshire require more than self-declaration of citizenship under penalty of perjury. The CMS guidance spells out the types of documents that must be presented to establish citizenship and identity, ruling out sworn statements as proof of citizenship except in rare cases.

The Kaiser study examines the experience of New York, which has required documentation of citizenship since the 1970s, to assess the feasibility of complying with the guidelines without causing major loss of coverage.

New York offers applicants assistance in meeting its documentation requirements that may not exist in other states, the study notes. Because of that assistance and a flexible approach toward obtaining compliance, most applicants are able to meet the documentation requirements, it adds. But documentation can be a particular barrier to entry into Medicaid for the elderly, the institutionalized, the homeless, the mentally ill, and people with "transient or unstable housing," the report says.

Based on New York's experience, CMS should change its requirements so U.S. citizens who receive Medicare and income assistance from the federal Supplemental Security Income (SSI) program are exempt from documenting citizenship in Medicaid, the study says.

A "hierarchy" of acceptable documentation laid out by the CMS guidelines is too hard to administer, said the study, which is based on interviews with state and local Medicaid officials in New York and with individuals who provide enrollment assistance in the state.

Tracking whether an applicant first attempted to supply a more preferable document is too burdensome, the study says. New York "does not assign a hierarchy of reliability . . . to citizenship documents." Also, the CMS guidelines require types of proof of identity that New York doesn't, it said. "For example, while a birth certificate documents both citizenship and identity in New York, this practice would not be acceptable" without modifying the CMS guidelines.

Another difference is that New York accepts copies of citizenship documents and does not require originals or certified copies. "The prospect of now requiring beneficiaries to mail original documents to New York's local social services offices, to be mailed back at a later date, is unrealistic and encourages people to surrender valuable and important documents best kept in their own possession," the study said.

"The alternative prospect of abandoning a successful mail-in renewal system to require in-person encounters for the purposes of presenting original documents is equally untenable."

The report also asserts that the cost and complexity of obtaining or replacing original or certified copies of citizenship documents would be a significant barrier to Medicaid coverage. Those costs range from $10 to $220, it said. To the extent New York State picks up those costs, it faces significant new administrative expenses, the report added.

"The practical implications of requiring original citizenship documents are potentially enormous. . . . many of the state's 4 million Medicaid beneficiaries may have to present original documents in order to retain their Medicaid benefits," the report said.

The June 9 CMS letter noted that the agency will monitor the quality of documentation relied on by states to establish citizenship and identity. CMS "will require corrective action to ensure the most reliable evidence is routinely being obtained," the letter said.

The letter specified that existing beneficiaries be given a "reasonable opportunity" to document citizenship before loss of coverage. If an applicant or current beneficiary makes a "good faith" effort to document citizenship but is unable to do so, the state should provide assistance, the CMS letter said.

But the Kaiser study said states should be "obligated" to provide help, not just told they "should" do so.

Leading the charge for the new requirements were two House Republicans from Georgia, Nathan Deal and Charlie Norwood, who say they are needed to keep illegal immigrants from taking health care resources away from U.S. citizens.

Norwood spokesman John Stone said there is enough flexibility in the requirements to permit enforcement to begin July 1. "It's not like everybody's going to have to be verified by July 1," he said. Existing beneficiaries come up for renewal at different times in the coming months, he said. "It's next year some time for a lot of folks." Stone added that as long as a good faith effort is under way to find documents, coverage will continue. "They're not kicked off while the social worker is looking for documentation," he said.

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