Individuals seeking care through Medicaid (Medi-Cal in California) beginning on July 1 will be required under federal law to show proof of U.S. citizenship — such as a birth certificate, passport or another form of identification. The new requirement will apply to all Medicaid applications submitted after July 1, 2006, as well as all applications to renew Medicaid coverage. (In most cases, Medicaid beneficiaries must renew their coverage every six months.) This means that in the first six to twelve months, states will have to check citizenship documents for more than 50 million beneficiaries.
This requirement was included in the Deficit Reduction Act of 2005, which President Bush signed into law earlier this year. The provision’s intent is to prevent undocumented immigrants from claiming to be citizens in order to receive benefits only provided to legal residents. Under federal law, undocumented immigrants can receive only emergency care through Medicaid. Many advocates and health care professionals are concerned that with the new citizenship requirements, millions of Medicaid beneficiaries will not be able to produce the needed documentation and will have difficulty receiving health services. According to a report from the Center on Budget and Policy Priorities (CBPP), the people most at risk for losing their Medicaid because of not having the required documents include the following:
- Some 12 million African Americans, including 800,000 elderly African Americans. These people will be subject to the new requirement between July 2006 and June 2007, and are at particular risk of having their Medicaid coverage delayed, denied, or canceled because many elderly African Americans have no birth certificate. Many were born in a time when racial discrimination in hospital admissions prevented mothers from giving birth at a hospital. As a result, their births often were not officially registered, and no birth certificates were given. (CBPP cites one study that estimates that about one in five African Americans born in the 1939-1940 period lack a birth certificate.)
- Adults without a high-school diploma, adults living in rural areas (9 percent of both groups reported that they lack the required documents, according to CBPP survey), and senior citizens aged 65 or older (7 percent of whom reported in a CBPP survey that they lack the required documents);
- People who have a sudden medical emergency and need Medicaid coverage immediately but cannot get their documents quickly;
- People who are homeless, mentally ill, or suffering from dementia or a disease like Alzheimer’s;
- People who are in nursing homes or are severely disabled and would have difficulty getting access to their birth certificate; and
- People whose personal documents have been destroyed by disasters such as fires, hurricanes or earthquakes.
Besides putting millions of Medicaid beneficiaries in jeopardy of loosing their coverage, this new requirement also puts up another barrier for people newly applying for Medicaid. Obtaining these documents, for those who do not have them, can take substantial time and costs money. In California, for example, it generally takes 10 to 12 weeks to get a birth certificate from the county office in the county where the birth occurred, and it can take six to eight months if the information submitted is not complete. Also, the cost of getting duplicate birth certificates or passports would effectively add an application fee to Medicaid for many people, potentially deterring many from entering the program and causing them to remain uninsured. A birth certificate can cost $5-23; a passport can cost $87-97.
In addition, according to the CBPP report referenced above, a recent review by the federal government found that states’ existing policies to document citizenship are effective and that no new federal requirements are needed in this area. Federal law already requires immigrants who apply for Medicaid to provide proof of their legal immigration status. States demand such documents on their Medicaid applications and take other steps to verify immigrants’ legal status. When people apply as citizens, they normally attest, under penalty of perjury, that they are citizens, and states usually do not require documentation of citizenship on a routine basis. However, if there is any question about the citizenship of an applicant, almost all states require documentation of citizenship.
Health and Human Services’ Office of Inspector General (OIG) also conducted a comprehensive review of state policies in this area and issued a report in July 2005. After studying the evidence, OIG did not recommend a new requirement for documentation of citizenship. The Centers for Medicare and Medicaid Services agreed as well, reporting it has no evidence of a problem in this area. Despite these findings, however, the DRA demands this onerous requirement.
Implementing this new requirement will increase costs for states and health care providers as well. In the above-mentioned OIG study, state administrators informed OIG that requiring birth certificates or passports would increase state administrative burdens and slow eligibility processing. States would have to notify applicants of the requirement, check their documents, keep records that the documents were submitted, delay enrollment if people cannot locate the documents, and in some cases, try to help people locate the documents. One state estimates that the requirement will add about 15 minutes of administrative effort per beneficiary.
While this new law is intended to prevent ineligible persons from receiving Medicaid, its consequences, costs, and implementation time are substantial and could possibly deprive large numbers of eligible persons of the health coverage they need. For more information on this law, see three additional CBPP reports and a report from the National Health Law Program linked below:
- “Survey Indicates Deficit Reduction Act Jeopardizes Medicaid Coverage for 3 to 5 Million U.S. Citizens,” revised February 17, 2006;
- “New Requirement for Birth Certificates or Passports Could Threaten Medicaid Coverage for Vulnerable Beneficiaries: A State-By-State Analysis,” revised February 17, 2006;
- “New Medicaid Requirement Is Unnecessary and Could Impede Citizens’ Coverage,” revised January 4, 2006.
- “The DRA’s Medicaid Citizenship Documentation Requirements,” National Health Law Program, May 24, 2006.
Information for this article was contributed in part by the Center on Budget and Policy Priorities report, The New Medicaid Citizenship Documentation Requirement: A Brief Overview, April 20, 2006; a California Healthline article, Citizenship Proof Required for Medicaid Services, April 17, 2006; and a California Healthline article, Medicaid Proof-of-Citizenship Law To Take Effect July 1, April 11, 2006.