Medicaid’s New Proof-of-Citizenship Requirements Gain Some Flexibility

Scrambling to keep millions of low-income U.S. citizens from unintentionally being denied healthcare benefits, federal officials Thursday proposed alternatives that states can use to carry out a controversial law requiring Medicaid recipients to prove their citizenship.

The law, which took effect July 1, requires new applicants and current beneficiaries to submit such documents as passports to establish their legal right to benefits. But many of the 50 million people covered by Medicaid lack such documentation, and advocates and state officials feared that as many as 3 million could lose benefits.

In California, where Medicaid is known as Medi-Cal, experts estimated that about 650,000 of nearly 7 million beneficiaries might not be able to comply with the law’s requirements. They included people with severe disabilities and many nursing home residents.

Advocates say it is not unusual to find people in their 70s and 80s who lack birth certificates, particularly if they were born poor and in small towns.

“We want to make sure people eligible for Medicaid get their benefits, and we want to do it without imposing additional burdens on the states,” Mark McClellan, administrator of the Medicaid and Medicare programs, said in announcing the anxiously anticipated regulations.

“This recognizes the diversity of individuals and provides a range of ways citizenship status may be documented,” he explained.

The regulations, which would become final later this summer, would exempt from the documentation requirements some 8 million elderly and disabled people who are enrolled in Medicare or receiving Supplemental Security Income through Social Security.

Additionally, people who are making a “good faith effort” to prove their citizenship would not face loss of coverage.

Instead of requiring beneficiaries to take steps such as obtaining a passport, states could use several different kinds of government program databases to establish eligibility.

In rare cases where no documentation of citizenship can be found, sworn affidavits from the beneficiary and at least one other person could be used.

Moreover, states that provide Medicaid coverage for legal immigrants would be able to keep using their current procedures.

Advocates for the poor and the elderly reacted cautiously to the announcement late Thursday afternoon. California officials said they needed more time to analyze the 94-page regulation.

“We are estimating the law will be implemented in August,” said Lea Brooks, a spokeswoman for the state.

It was unclear how the government’s action would affect a lawsuit seeking to block the new law, filed last week by beneficiaries and their advocates. An initial hearing on the case is scheduled today in U.S. District Court in Chicago.

Some advocates said the proposed rules move in the right direction, just not far enough.

“The exemption of seniors and people with disabilities ... is a commendable development,” said Ron Pollack, head of the Families USA advocacy group. “Numerous other people who need healthcare the most -- such as foster children, the homeless and people victimized by a natural disaster -- may still lose Medicaid coverage and join the ranks of the uninsured, and that should be corrected.”

McClellan said federal officials want to cooperate in resolving any problems states might run into, but he emphasized that the law is the law. “States know this is a condition of the Medicaid statute -- it’s a requirement for their receiving federal matching funds,” he said.

Congress passed the citizenship documentation requirement last year as part of a deficit reduction bill. Previously, beneficiaries could sign a form attesting to their citizenship, under penalty of perjury.

Although the new law is estimated to generate some modest savings for taxpayers, federal and state officials have said that there is no evidence of widespread Medicaid fraud by immigrants, whether legal or undocumented. Illegal immigrants in particular run the risk of being discovered and deported if they apply for government benefits.

Hospitals are still required to provide emergency care for all, regardless of the new documentation requirement for Medicaid.