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Medicaid Citizenship Requirements
Medicaid Citizenship Requirements
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Medicaid Citizenship & Identity Requirements
"“Politics is =
the
art..."
A Solution Looking =
for a
Problem?
History
DRA Medicaid Reduct=
ions
New Requirement =
When CMS Sneezes…
What the States are
Reporting
Heartaches by the
Numbers
Comment from Kansas=
Comment from Louisi=
ana
What Else the State=
s are
Reporting
1st Year
Administrative Costs
The Way We Were =
But…
Lawsuit Filed
Michigan’s Plan to
Implement
Medical Programs That Require Proof of
Citizenship and Identity
Proving
Citizenship PEM 225 of Michigan Policy
Medical Programs Th=
at Do
Not Require Proof of Citizenship or Identity PEM 225 of Michigan Policy
Exemptions PEM 225 of Michigan Policy
Levels of Evidence =
of
Citizenship PEM 225 of Michigan Policy
1st Leve=
l of
Documentation of Citizenship PEM 225 of Michigan Policy
2nd Level of
Documentation of Citizenship
Data Matches Allowe=
d by
CMS to Prove Citizenship
Affidavitsth Level of Documentation
Vital Statistics
Web Links to Vital
Statistics Sites
Identity for MA &am=
p; AMP
Allowable Types of
Verification of Identity PEM 221 of Michigan Policy
Verifications and
Collateral Contacts PAM 130 of Michigan Policy
DHS Role in Getting=
Proof
of Citizenship/Identity PAM 130 of Michigan Policy
How Much Time is Gi=
ven? PAM 130 of Michigan Policy
Getting Proof of
Citizenship/Identity PAM 130 of Michigan Policy
What if the Documen=
tation
Cannot be Obtained?
L & S Study
Problem Cases
L & S and MHA
Comments
DHS Policy Question=
DHS Policy Question=
DHS Policy Question=
DHS Policy Question=
DHS Policy Question=
What Hospitals &
Clinics Can Do to Help Themselves
Hospital & Clin=
ics –
For Additional
Information
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Medicaid Citizenship & Identity Requirements
Section 6036 of the=
Deficit
Reduction Act of 2005
"“Politics is =
the
art..."
“Politics is the ar=
t of looking
for trouble,
finding it whether =
it exists or
not,
diagnosing it incor=
rectly, and
applying the wrong remedy.”
Quote by Larry Hard=
iman
A Solution Looking =
for a
Problem?
“The intent is to e=
nsure that
Medicaid beneficiaries who claim to be citizens are actually citizens wit=
hout
imposing undue burdens on them or the states.”
Quote from the CMS =
Medicaid
Fact Sheet, July 06, 2006
History
Signed into law by =
President
February 8, 2006
Effective date was =
July 1, 2006
CMS issued interim =
regulations
on June 9th – left no time for states to implement on July 1st.
Michigan will imple=
ment for all
applications filed and annual redeterminations as of April 1, 2007 =
States lose federal=
match for
Medicaid if they fail to implement
DRA Medicaid Reduct=
ions
The White House’ Pr=
ojections
2006 – 2010: $39 B<=
br>
$4.8 B in Medicaid
2006 – 2015: $99 B<=
br>
$39 B in Medicaid
The Congressional B=
udget
Office’s MA Savings Projections
$11.5 B in Medicaid=
$43.2 B in Medicaid=
New Requirement =
Must prove citizens=
hip, even
though no problem with fraud was identified
Must also prove ide=
ntity
Congressional Budge=
t office
estimated that 35,000 enrollees would lose eligibility
Center on Budget an=
d Policy
Priorities estimated that at least 1 million could experience delays or be
denied Medicaid
When CMS Sneezes…
CMS wrote rules to =
comply with
legislation
More restrictive th=
an the law
Requirements listed=
in
unnecessary hierarchy
US medical provider=
s catch
colds
What the States are
Reporting
So far, twelve stat=
es have
reported the initial impact of the citizenship requirements
The number of Medic=
aid
recipients losing their benefits was substantially underestimated <=
/td>
Those being adverse=
ly affected
are primarily U.S. citizens (mostly children) who are otherwise eligible =
for
Medicaid
Heartaches by the
Numbers
Florida: 63,000
New Mexico 10,000
Louisiana: 55,000
Kansas: 20,000
Wisconsin: 14,034
Iowa: 5,700 <=
/td>
Ohio: 39,000 =
Virginia: 13,300
New Hampshire: 1275=
Total: 221,309
Comment from Kansas=
“While we understan=
d that the
new law targets illegal immigrants, we must point out that the impact of =
the
law in our state is mostly falling on eligible citizens.”
Andrew Allison, Dep=
uty Director
Kansas Health Policy Authority
Comment from Louisi=
ana
“These numbers [Med=
icaid
enrollment decline] are not driven by the loss of population from New Orl=
eans
and other parishes affected by Hurricane Katrina…We are quite confident t=
hat
the overwhelming majority of these children are citizens — born right her=
e in
Louisiana — and not ineligible alien children”
J. Ruth Kennedy, De=
puty
Medicaid Director
Louisiana Departmen=
t of Health
and Hospitals
What Else the State=
s are
Reporting
Significant increas=
es in
administrative costs
Longer delays in el=
igibility
determinations.
1st Year
Administrative Costs
Illinois, $16 - $19=
M
Arizona, $10 M
Colorado, $2.8 M
Washington, $2.7 M<=
/font>
Wisconsin, $1.3 M
Minnesota, $1.3 M
The Way We Were =
Social Security Act=
of 1998
allowed self-declaration in
writing.
In 1998, 46 states =
and the D.C.
permitted self-declaration
MT, NY, NH and TX d=
id not
But…
Two Georgia Congres=
smen bring
the politics of illegal immigration to the DRA ’05
Q: Was there a national problem of illeg=
al
immigrants receiving full Medicaid benefits fraudulently?
A: No.
There is no compelling documentation of fraudulent self-declaratio=
ns
by immigrants, whether legal or illegal.
Lawsuit Filed
“It’s a bureaucrati=
c morass,
legally wrong and, I absolutely believe from a moral perspective, it’s wr=
ong,
fundamentally wrong.”
The Hon. Christine =
Gregoire,
Governor State of Washington
Michigan’s Plan to
Implement
Effective April 1, =
2007
Delayed after advoc=
acy
Structured to assis=
t clients as
much as possible within constraints of budget
Contains ambiguitie=
s which will
be resolved based upon experience
Medical Programs That Require Proof of
Citizenship and Identity
Proving
Citizenship PEM 225 of Michigan Policy
New full Medicaid e=
nrollments
At redetermination =
of
eligibility for current full Medicaid recipients
(should not remove =
from
Medicaid as long as cooperating)
Citizenship is prov=
en only one
time for Medicaid (and that time is now).
Medical Programs Th=
at Do
Not Require Proof of Citizenship or Identity PEM 225 of Michigan Policy
Emergency Services =
Only
Medicaid
Adult Medical Progr=
am *
* AMP, which is the=
Adult
Benefit Waiver program, requires identity documentation if identity is
questionable. It is not currentl=
y open
for enrollment.
Exemptions PEM 225 of Michigan Policy
Citizens Who Do Not=
Have to
Document Citizenship
Medicare recipients=
SSI recipients
SSDI recipients (sh=
ould be
added)
Newborns & Safe=
Delivery
Babies
Foster Care Childre=
n
Levels of Evidence =
of
Citizenship PEM 225 of Michigan Policy
Per CMS, client can=
not move to
lower tiers unless information at the previous tier is unavailable =
1st tier=
has 3
sources
2nd tier=
has 10
sources
3rd tier=
has 2
sources (non-government)
4th tier=
has 7
sources (rarely used)
1st Leve=
l of
Documentation of Citizenship PEM 225 of Michigan Policy
U.S. Passport
Under age 16, cost=
s $82
Certificate of Naturalization
Certificate of U.S. Citizenship
** These documents =
can also be
used to verify identity
2nd Level of
Documentation of Citizenship
U. S. Birth Certificate
plus
Driver’s License or=
pictured
State ID
Alternatives also listed
Data Matches Allowe=
d by
CMS to Prove Citizenship
SDX (SSI beneficiaries)
State’s Vital Stati=
stics
Neither are in plac=
e In
Michigan at this time
Affidavitsth Level of Documentation
Requires affidavits=
from at
least 2 individuals
One must not be a r=
elative of
the client
Both must have pers=
onal
knowledge of the event establishing the client’s claim of citizenship
The Devil is in the=
details: Must
give proof of their own citizenship & identity
Sign under penalty =
of perjury
Include information=
explaining
why the documentary evidence establishing the claim of citizenship does n=
ot
exist or cannot be obtained
Vital Statistics
Michigan
$26 for regular pro=
cessing
(except for senior citizens requesting their own birth certificate), abou=
t 4
weeks
$10 extra for exped=
ited
processing, no more than 2 weeks
Online orders requi=
re using a
credit card payment
Those who must pay =
for
documents will be doing so not knowing whether or not they will otherwise
qualify for Medicaid benefits (Example:
Will the state determine they are disabled?)
Web Links to Vital
Statistics Sites
U.S. HHS, National =
Center for
Health Services
http://www.cdc.gov/=
nchs/howto/w2w/w2welcom.htm
United States Vital=
Records
Part of Ancestors.c=
om
http://www.vitalrec.com/
Identity for MA &am=
p; AMP
MA: The identity of=
U.S.
citizens must be verified for clients age 16 and above.
Identity must be ve=
rified at
each application and annual redetermination
Non-citizens are no=
t required
to verify identity unless questionable.
AMP: Client identit=
y does not
have to be verified unless it is questionable
Allowable Types of
Verification of Identity PEM 221 of Michigan Policy
Some types of docum=
ents used to
verify identity include:
Current driver’s li=
cense with
photo
State issued ID wit=
h photo
School issued ID wi=
th photo
Documents indicatin=
g the
applicant’s/client’s receipt of benefits under a program requiring
verification of identity (e.g., SSI, RSDI)
Verifications and
Collateral Contacts PAM 130 of Michigan Policy
“Documents used to =
verify
citizenship and identity may be originals or copies of the original
document.”
“The client must ob=
tain
required verification, but you ( the state worker) must assist if they ne=
ed
and request help.”
DHS Role in Getting=
Proof
of Citizenship/Identity PAM 130 of Michigan Policy
When the applicant =
or client
ask DHS to help obtain the required documentation, DHS efforts must inclu=
de
but are not limited to:
State to state writ=
ten and
verbal inquiries
Interviews with fri=
ends and
relatives
Use of computerized=
records
Note: The state has=
no funds to
pay for needed documents
How Much Time is Gi=
ven? PAM 130 of Michigan Policy
“Allow the client 1=
0 calendar
days … to provide the verification you request.”
“If the client cann=
ot provide
the verification despite a reasonable effort, extend the time limit at le=
ast
once.”
Getting Proof of
Citizenship/Identity PAM 130 of Michigan Policy
DHS Practice Regard=
ing a 2nd
Extension Can Vary by County and by Caseworker
Definition of Reaso=
nable
Effort…Always a Question Subject to Interpretation
What if the Documen=
tation
Cannot be Obtained?
The caseworker cann=
ot deny the
application or close the case as long as the client is cooperating with D=
HS
A DCH Referral is M=
andatory if
Information cannot be obtained (also subject to state worker interpretati=
on)
L & S Study
Surveyed 2,500 Medi=
caid
Applicants
Found that approxim=
ately 1/3
did not possess the required documents
Approximately 1/4 o=
f those not
having the documents were born o=
utside
of Michigan
Problem Cases
Homeless
Adopted
A Minority Group Me=
mber Born in
the South
Native Americans
Hurricane Katrina V=
ictims
Unconscious <=
/td>
Mentally Incapacita=
ted
Deceased
L & S and MHA
Comments
MHA and L & S S=
ent Comments
to DHS
The Comments Addres=
sed
Additional Concerns - Not Written in Policy
Requested Revision =
to Forms
Requested Creating =
Additional
Forms
DHS Policy Question=
Will DHS process th=
e case for a
MRT disability decision and the DCH decision on citizenship concurrently?=
If not, the case ma=
y be
unnecessarily delayed for eligibility determination.
DHS Policy Question=
When DHS makes a
citizenship/identity determination referral to DCH will the Medicaid
application continue to pend (and not be denied)?
How long will it ta=
ke the DCH
to make that determination?
DHS Policy Question=
If the client canno=
t afford to
pay to obtain the documentation, will DHS accept 3rd and 4th l=
evel
documentation?
Is lack of funding =
a valid
reason not to order birth certificates or obtain state ID, or will the client will be denied or lose ben=
efits?
DHS Policy Question=
Affidavits to prove=
citizenship
are to be used only in rare circumstances according to DHS policy. =
Who makes the decis=
ion on
whether other tiers of information are “unavailable”?
“Personal knowledge=
” of a birth
is a difficult legal standard to meet.
Who will define what language is acceptable?
How will DHS worker=
s assist the
client with affidavits, if necessary, when they have no approved form to
utilize and are not typically notaries?
DHS Policy Question=
Who will pay for th=
e costs of
low-income applicants to obtain the documentation needed to verify
citizenship?
CMS requires public
outreach. Who will do it and how=
will
it be done?
What Hospitals &
Clinics Can Do to Help Themselves
Inquire about citiz=
enship upon
admission
Copy driver license=
s and state
ID cards upon admission
If your Financial C=
ounselors
deal directly with DHS and your client had a previous DHS case record, ask
the caseworker to check that record for the required documents
Have a sound Medica=
id
eligibility program in place
Hospital & Clin=
ics –
Hospitals continue =
to struggle
with the contradictory problems of providing treatment to those in need,
while trying to find a way to pay for the mounting costs of health care
services to the uninsured.
US Congress and CMS=
have
increased that challenge, and some DSH hospitals may lose DSH eligibility
altogether as a result!
For Additional
Information
L & S Associate=
s web page
includes links to:
DHS citizenship/ide=
ntity
information
CMS citizenship/ide=
ntity
information
http://www.lsamedic=
aidspecialists.com/index.html
To be added to our =
email list
for updates to this information and occasional policy updates, please sen=
d an
email to LRhodes@LSAservices.com or AGarbinski@LSAservices.com
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