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Medicaid News
States Brace for Federal Mandate that Medicaid
Recipients Prove Citizenship
New rule by HHS becomes effective on July 1
June 14, 2006 – States are bracing for the impact
of a new rule from Health and Human Services that mandates Medicaid
participants show proof of citizenship. This health program for the poor
has always been only for U.S. citizens and legal immigrants, but this is
the first time the federal government has told states they must check to
be sure those seeking help have proof of citizenship. The order is
effective on July 1.
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In New Mexico, for example, the new law will affect
at least 400,000 people at some point this year, according to
The New Mexican. "But it won't hit everyone right away."
"The first people it will affect are those who need
to recertify their Medicaid coverage in July. Once a year, Medicaid
recipients must renew their coverage, which involves showing their
income still falls within program guidelines," the newspaper reports.
"We will help New Mexicans, especially Native
Americans who may not have a birth certificate, get the proper documents
needed to stay covered," New Mexico Human Services Department Secretary
Pamela Hyde, said in a news release. "We want to make sure that New
Mexicans continue to get the health-care coverage they need to stay
healthy."
"The new documentation requirement is outlined in
Section 6036 of the Deficit Reduction Act of 2005 (DRA) and is intended
to ensure that Medicaid beneficiaries are citizens without imposing
undue burdens on them or the states," said the statement issued by HHS.
"American citizenship or legal immigration status
has always been a requirement for Medicaid eligibility, however,
beneficiaries could assert their status by checking a box on a form, the
HHS statement explained.
The new rule requires actual documentary evidence
before Medicaid eligibility is granted or renewed beginning July 1. The
provision requires that a person provide both evidence of citizenship
and identity.
In many cases, a single document will be enough to
establish both citizenship and identity, such as a passport.
However, if secondary documentation is used, such
as a birth certificate, the individual will also need evidence of their
identity. Once citizenship has been proven, it need not be documented
again with each eligibility renewal unless later evidence raises a
question.
Recognizing the diversity of beneficiaries served
by Medicaid, the guidelines provide for a range of ways that citizenship
status and personal identity may be documented, according to HHS
If other forms of documentation cannot be obtained,
documentation may be provided by a written affidavit, signed under
penalty of perjury, from two citizens, one of whom cannot be related to
the applicant or recipient, who have specific knowledge of a
beneficiary’s citizenship status, the statement says.
HHS adds, that affidavits can only be used in rare
circumstances. Additional types of documentation, such as school
records, may be used for children. Current beneficiaries should not
lose benefits during the period in which they are undertaking a
good-faith effort to provide documentation to the state.
HHS says the guidance letter to state Medicaid
directors reflects extensive input from experts and groups, such as the
National Association of State Medicaid Directors, the National
Association of Community Health Centers, the National Mental Health
Association and the Tribal Technical Advisory Group to CMS.
Following are the guidelines published by HHS
Overview of New Guidance on Citizenship
Documentation for Medicaid Benefits
Guidance Details – June 12, 2006
Documentary Evidence
The law specifies certain forms of acceptable
evidence of citizenship and identity, and provides for the use of
additional forms of documentation as established by federal regulations,
when appropriate. Today’s guidance outlines acceptable additional forms
of documentary evidence.
The guidance adopts a hierarchical approach already
in use by other programs in which documentary evidence of citizenship
and identity is sought first from a list of primary documents. If an
applicant or recipient presents evidence from the listing of primary
documentation, no other information would be required. When such
evidence cannot be obtained, the state will look to the next tier of
acceptable forms of evidence.
A state must first seek documents from the primary
list before looking to the secondary or tertiary lists.
In particular, the following forms of documentation
may be accepted:
Acceptable primary documentation for
identification and citizenship:
● A U.S. Passport.
● A Certificate of Naturalization (DHS Forms N-550
or N-570).
● A Certificate of U.S. Citizenship (DHS Forms
N-560 or N-561).
Acceptable secondary documentation to verify
proof of citizenship (an identity document is also required):
● A U.S. birth certificate.
● A Certification of birth issued by the
Department of State (Form DS-1350).
● A Report of Birth Abroad of a U.S. Citizen
(Form FS-240).
● A Certification of Birth Abroad (FS-545).
● A U.S. Citizen I.D. card (DHS Form I-197).
● An American Indian Card issued by the
Department of Homeland Security with the classification code “KIC”.
(Issued by DHS to identify U.S. citizen members of the Texas Band of
Kickapoos living near the U.S./Mexican border).
● Final adoption decree
● Evidence of civil service employment by
the U.S. government before June 1976,
● An official military record of service
showing a U.S. place of birth
● A Northern Mariana Identification Card.
(Issued by the INS to a collectively naturalized citizen of the United
States who was born in the Northern Mariana Islands before November 4,
1986.).
Acceptable third level documentation to verify
proof of citizenship:
● Extract of U.S. hospital record of birth
established at the time of the person’s birth and was created at least 5
years before the initial application date and indicates a U.S. place of
birth.
● Life or health or other insurance record showing
a U.S. place of birth and was created at least 5 years before the
initial application date
Acceptable fourth level documentation to verify
proof of citizenship:
● Federal or State census record showing U.S.
citizenship or a U.S. place of birth.
● Institutional admission papers from a nursing
home, skilled nursing care facility or other institution and was created
at least 5 years before the initial application date and indicates a
U.S. place of birth.
● Medical (clinic, doctor, or hospital) record and
was created at least 5 years before the initial application date and
indicates a U.S. place of birth unless the application is for a child
under 5
● Other document that was created at least five
years before the application for Medicaid. These documents are Seneca
Indian tribal census record, Bureau of Indian Affairs tribal census
records of the Navaho Indians, U.S. StateVital Statistics official
notification of birth registration, an amended U.S. public birth record
that is amended more than 5 years after the person’s birth or a
statement signed by the physician or midwife who was in attendance at
the time of birth.
Written affidavit.
Written affidavits may be used only in rare
circumstances when the state is unable to secure evidence of citizenship
from another listing. The affidavits must be supplied by at least two
individuals, one of whom is not related to the applicant or recipient.
Each must attest to having personal knowledge of the event(s)
establishing the applicant’s or recipient’s claim of citizenship.
The individuals making the affidavit must be able
to prove their own citizenship and identity for the affidavit to be
accepted. Those making affidavits will be subject to prosecution for
perjury. If the persons claiming knowledge of another’s citizenship has
information which explains why documentary evidence establishing the
applicant’s claim of citizenship does not exist or cannot be readily
obtained, the affidavit should contain this information as well. A
second affidavit from the applicant/recipient or other knowledgeable
individual explaining why documentary evidence does not exist or cannot
be readily obtained must also be requested.
Acceptable documentation to verify proof of
identity:
● A current state driver’s license bearing the
individual’s picture or State identity document also with the
individual’s picture.
● Certificate of Indian Blood, or other U.S.
American Indian/Alaska Native tribal document.
● Any identity document described in section
274A(b)(1)(D) of the Immigration and Nationality Act.
Children who are age 16 or younger may have their
identity documented using other means, when the child does not have or
cannot get any document on the preceding lists.
● School identification card with a photograph.
● Military dependent’s identification card if it
contains a photograph.
● School record that shows date and place of birth
and parent(s) name.
● Clinic, doctor or hospital record showing date
of birth.
● Daycare or nursery school record showing date
and place of birth.
● Affidavit signed under penalty of perjury by a
parent or guardian attesting to the child’s identity.
Driver’s License Documentation to Establish Both
Citizenship and Identification
Section 6036(a)(3)(B)(iv) of the DRA permits the
use of a valid state-issued driver’s license or other identity document
described in Section 274A(b)(1)(D) of the Immigration and Nationality
Act, but only if the state issuing the license or such document requires
proof of United States citizenship before issuance of such license or
document or obtains a Social Security number from the applicant and
verifies before certification that such number is valid and assigned to
the applicant who is a citizen. CMS is not currently aware that any
state has these processes in place at this time. Therefore, until such
time that a state has this requirement in place this documentation may
not be accepted.
Reasonable Opportunity
At the time of application or redetermination, the
state must give an applicant or recipient a “reasonable opportunity” to
present documents establishing U.S. citizenship or nationality and
identity. The guidance advises:
● An individual who is already enrolled in
Medicaid will remain eligible if he/she continuously shows a good faith
effort to present satisfactory evidence of citizenship and identity.
● Applicants for Medicaid should not be made
eligible until they have presented the required evidence.
● If the applicant or recipient tries in good
faith to present satisfactory documentation, but is unable because the
documents are not available, the state should assist the individual in
securing these documents.
● If the applicant or recipient cannot obtain the
necessary documents and needs assistance (i.e., is homeless, mentally
impaired, or physically incapacitated), and lacks someone who can act on
their behalf, then the state should assist the applicant or recipient to
document U.S. citizenship and identity.
Compliance
As with other Medicaid program requirements, states
must implement an effective process for assuring compliance with
documentation of citizenship in order to obtain federal matching funds,
and effective compliance will be part of Medicaid program integrity
monitoring. In particular, audit processes will track the extent to
which states rely on lower (third and fourth level) categories of
documentation, and on affidavits, with the expectation that such
categories would be used relatively infrequently and less over time, as
state processes and beneficiary documentation improves.
States will receive the normal 50 percent match for
administrative expenses related to implementation of the new law.
Outreach
The Centers for Medicare & Medicaid Services, the
agency that oversees the Medicaid program, will launch an aggressive
outreach program to educate states and interested groups about the new
requirement. These outreach efforts include presentations to interested
groups and tools that states may use to help applicants and recipients
understand the requirement.
The tools will include talking points, questions
and answers, a sample press release, drop-in article and lists of
acceptable documents. The agency will also work closely with states to
help them reach out to their current Medicaid enrollees and the general
public outlining the new rules. CMS will hold training sessions with
state officials including regular telephone consultations during which
the agency will provide whatever technical assistance the states
request. CMS will also provide speakers at national conferences of
interested groups such as tribal organizations and advocacy groups for
minority communities.
For more information about the citizenship
documentation requirement, go to:
http://www.cms.hhs.gov/MedicaidEligibility/05_ProofofCitizenship.asp#TopOfPage
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