Citizenship Rule May Penalize Applicants With Mental Illness

A Medicaid-eligibility requirement instituted in 2006 appears to have led many beneficiaries to lose their access to the program and others to be denied enrollment, according to early indicators tracked in six states.

The first six months of a new federal requirement that Medicaid officials obtain documents proving citizenship from new or renewing Medicaid beneficiaries has resulted in many people—especially children—losing access to care in the program that provides health care for the poorest segment of the population. The findings from the first six states to report the impact of the proof-of-citizenship requirement were collected in a February report from the Center on Budget and Policy Priorities (CBPP), a nonprofit organization that studies the impact of the federal budget and other policies on low-income Americans.

“The new requirement also appears to be reversing part of the progress that states made over the past decade in streamlining access to Medicaid for individuals who qualify, and especially for children,” wrote Donna Cohen Ross, outreach director for CBPP and author of the report.

The policy, mandated by the Deficit Reduction Act enacted in February 2006, was implemented by the Centers for Medicare and Medicaid Services (CMS) in July 2006, and final regulations were released in mid-August.

Documents that can be used to prove citizenship include a U.S. passport, certificate of U.S. naturalization, and certificate of U.S. citizenship. Other documents—such as a U.S. birth certificate or official military service record showing a U.S. place of birth—are acceptable when accompanied by proof of identity.

In the past, most states allowed beneficiaries to attest to U.S. citizenship under penalty of perjury. Documentation was required only from those whose citizenship status was questioned by Medicaid officials.

APA applauded the decision by CMS to allow states to exempt the approximately 8 million people already enrolled in Supplemental Security Income or Medicare programs from the new requirement. The rules also outlined alternatives that states could use as verification, including electronic data matches with other government agencies or, in rare circumstances, a written affidavit by two other citizens, one of whom must be unrelated to the applicant. Most states opted to take that less-restrictive route.

Critics of the citizenship policy, including APA, maintain that it endangers the health care of Medicaid beneficiaries not included in the exemptions, who could become confused and possibly dropped because they cannot produce the necessary paperwork. The Center on Budget and Policy Priorities estimated in September 2006 that when fully implemented, the requirements would affect about 38 million people in Medicaid and an estimated 10 million applicants.

Although Medicaid enrollment figures for all states since the new requirement was implemented are not yet reported, the researchers collected early data in the states where they were available—Wisconsin, Kansas, Iowa, Louisiana, Virginia, and New Hampshire.

All six states reported a “significant” drop in enrollment since the identification requirement was implemented, and Medicaid officials in those states attributed the trend primarily or wholly to the identification requirement. The states reported that they have denied or terminated Medicaid benefits because some beneficiaries or applicants cannot produce the required documents, despite appearing to be U.S. citizens. Medicaid officials also report application backlogs stemming from beneficiaries' inability to locate the required paperwork and from the administrative workload created by the requirement.

Drops in enrollment or denials of coverage linked to the citizenship documentation requirement included more than 14,000 people in Wisconsin and up to 20,000 people in Kansas. Louisiana reported a net loss of 7,500 children from its Medicaid program in fall 2006, despite a back-to-school outreach effort that usually results in an enrollment increase. The Louisiana officials said the drop was unrelated to the loss of the state's population to emigration after Hurricane Katrina.

The report concluded that the 3.1 percent decline in enrollment since July 2006 is unrelated to broader economic changes, because the Food Stamp Program, which usually closely tracks Medicaid enrollment, has had a 0.8 percent increase in caseloads in that time.

Congress enacted the new requirement over concerns that illegal immigrants were falsely claiming citizenship to receive Medicaid benefits, although the Office of Inspector General at the Department of Health and Human Services found no substantial evidence of such problems.

APA worked to convince the federal government to modify the proof-of-citizenship rule before beneficiaries with mental illness, who may have a particularly difficult time locating and providing the documentation, suffered the loss of coverage.

APA has urged further modifications of the rule through its partnership with the Campaign for Mental Health Reform. In a May 2006 letter to CMS, the campaign urged the agency to allow a broad list of other documents to demonstrate citizenship (Psychiatric News, August 1, 2006).

A copy of “New Medicaid Citizenship Documentation Requirement Is Taking a Toll: States Report Enrollment Is Down and Costs Are Up” is posted at<www.cbpp.org/2-2-07health.pdf>.▪