Matthew Gever

Many states are hustling to implement a new Medicaid requirement that some say will save them hundreds of thousands of dollars—but others say will add costs and confusion and will prevent low-income persons from getting the coverage and care they need.

Citizenship or legal immigration status always has been a requirement for Medicaid; however, many states have sought to reduce barriers to enrollment by allowing citizens to simply declare their status. Those who said they were legal immigrants were required in every state to provide documentary evidence. Self-attestation of citizenship is no longer acceptable.

If a recipient provides citizenship documents such as a U.S. birth certificate or a report of birth abroad of a U.S. citizen, citizenship will have been proven, but an identity document such as a current state driver’s license bearing the individual’s photo also will be required. The CMS guidance provides a lengthy list of documents that will be accepted as proof of citizenship or legal immigrant status, as well as documents that will be accepted as proof of identity, in descending order of preference. In rare circumstances, Medicaid may accept a written affidavit, signed by two citizens under penalty of perjury, as proof of citizenship. Additional types of documentation, such as school records, may be used as proof of identity for children.

Effect on States Varied

Five states—Montana, New York, New Hampshire, Georgia and Texas—already require documentation verifying citizenship. For the other 45 states and the District of Columbia, an individual signed a declaration stating that he or she is a citizen.

“We are not changing what has always been required to be eligible for these benefits, but are adopting enhanced verification to further assure that only those eligible for services obtain them,” said Texas Rep. Dianne Delisi. “My concern is that we must look closely at the security features of the documents accepted to establish both citizenship and identity. Forged documents and identity theft are already major problems associated with illegal immigration. To make this new requirement work, we need to assure that the documents used to obtain services are legitimate.”

At least two states—Ohio and California –plan to delay implementation of the guidelines. Both cite the short notice given by CMS, saying they need more time to advise patients.

With a high population of both immigrants and Native Americans, many of whom do not have birth certificates, the new rules will pose quite a challenge in New Mexico, state officials said. The state has created a cross-agency team—with representatives from the Departments of Health, Aging and Long-Term Services, and Taxation and Revenue—that will determine ways to share electronic and other information that could help recipients document their eligibility.

“For example, an electronic match between Medicaid clients and the Department of Health’s Records could help prove citizenship for Medicaid clients born in New Mexico who do not have their birth certificates,” said Pamela Hyde, secretary of the state Human Services Department.

Officials in Arizona, which also has large immigrant and Native American populations, have been “diligent about going around the state, talking to hospitals and providers,” said Rainey Daye Holloway, with the Arizona Health Care Cost Containment System. The department has done a good job of training its staff on how to answer questions about documentation and does not expect to see a rise in costs, she added.

Louisiana is hoping to simplify matters by putting together two lists of acceptable documentation to assist Medicaid patients: one for people born in the United States, and one for people born abroad. But the recent hurricanes may slow things down. “The Office of Vital Records is still catching up on work from before the hurricane,” said Kristen Myer, spokeswoman for the Department of Health and Hospitals.

Some of the results:

• Detroit, Michigan’s “Mayor’s’ Time” increased participation in after-school programs from 20 percent to 50 percent;
• Philadelphia, Pennsylvania’s “Safe and Sound” helped to reduce youth homicides by 50 percent in the police districts where it operates, and increased funding for after-school programs by $90 million;
• Richmond, Virginia’s “Youth Matters” boosted the quality and quantity of early childhood programs;
• Oakland, California’s “Safe Passages” middle school strategy helped reduce suspensions due to violence by 72 percent;
• Baltimore, Maryland’s “Safe and Sound Campaign” increased the percentage of Baltimore children who enter kindergarten ready to learn from 27 percent in 2004 to 40 percent in 2005. 

Baltimore’s program was so successful that the state joined in to create the “Maryland Opportunity Compacts,” which are based on the idea that prevention and early intervention in problems such as substance abuse are more effective and less costly to taxpayers than letting such problems grow until they require foster care, juvenile detention or prison. Based on a program in San Diego, California, the first compact is aimed at reducing the amount of time that children of drug abusers spend in foster care. The state plans to funnel a large proportion of any money saved (from correctional institutions, for example) into programs for the youngsters and their parents.

Unlike most grant-funded projects, the UHI did not directly pay for services, said Jerry VanderWood, UHI chief of staff. Instead, the project took a “systems change” approach, ensuring that policy changes are implemented throughout systems or bureaucracies with different missions, cultures and funding streams. Getting time-pressed, skeptical officials in often under-funded agencies to work together toward a common goal can be very difficult, but it can be done, VanderWood said. A crucial factor in the UHI’s success are the “outside change agents” that focus on the “big picture” and create a non-partisan platform for change.

When the grant funds were spent, UHI leaders managed to secure other funds to keep the programs going. Mayor’s Time persuaded city officials to spend a portion of revenues from the city’s new casinos to expand recreational facilities; Oakland’s program taps Medicaid EPSDT and Medicare funds for in-school mental health-care.