Medicaid
States Reported That Citizenship Documentation Requirement Resulted in Enrollment Declines for Eligible Citizens and Posed Administrative Burdens Gao ID: GAO-07-889 June 28, 2007The Deficit Reduction Act of 2005 (DRA) included a provision that requires states to obtain documentary evidence of U.S. citizenship or nationality when determining eligibility of Medicaid applicants and current beneficiaries; self-attestation of citizenship and nationality is no longer acceptable. The Centers for Medicare & Medicaid Services (CMS) issued regulations states must follow in obtaining this documentation. Interested parties have raised concerns that efforts to comply with the requirement will cause eligible citizens to lose access to Medicaid coverage and will be costly for states to implement. GAO was asked to examine how the requirement has affected individuals' access to Medicaid benefits and assess the administrative and fiscal effects of implementing the requirement. To do this work, GAO surveyed state Medicaid offices in the 50 states and the District of Columbia about their perspectives on access issues and the administrative and fiscal effects of the requirement. GAO obtained complete responses from 44 states representing 71 percent of national Medicaid enrollment in fiscal year 2004. GAO also reviewed federal laws, regulations, and CMS guidance.
States reported that the citizenship documentation requirement resulted in barriers to access to Medicaid for some eligible citizens. Twenty-two of the 44 states reported declines in Medicaid enrollment due to the requirement, and a majority of these states attributed the declines to delays in or losses of Medicaid coverage for individuals who appeared to be eligible citizens. Of the remaining states, 12 reported that the requirement had no effect and 10 reported they did not know the requirement's effect on enrollment. Not all of the 22 states reporting declines could quantify enrollment declines due specifically to the requirement, but a state that had begun tracking the effect identified 18,000 individuals in the 7 months after implementation whose applications were denied or coverage was terminated for inability to provide the necessary documentation, though the state believed most of them to be eligible citizens. Further, states reporting a decline in enrollment varied in their impressions about the requirement's effect on enrollment after the first year of implementation. States' enrollment policies and whether an individual was an applicant or a beneficiary may have influenced the requirement's effect on access to Medicaid. For example, states that relied primarily on mail-in applications before the requirement were more likely to report declines in enrollment than states where individuals usually applied in person. In addition, the requirement may have more adversely affected applicants than beneficiaries because applicants were given less time to comply in some states and were not eligible for Medicaid benefits until they documented their citizenship. Although states reported investing resources to implement the requirement, potential fiscal benefits for the federal government and states are uncertain. All 44 states reported taking administrative measures to implement the requirement and assist individuals with compliance. In addition, 10 states reported that a total of $28 million was appropriated in state fiscal year 2007, and 15 states budgeted funds for implementation costs in state fiscal year 2008. Despite these measures, states reported that the requirement has increased the level of assistance needed by individuals and amount of time spent by states during the enrollment process. States specified two aspects of the requirement as increasing the burden for them and for individuals: that documents had to be originals and the list of acceptable documents was complex and did not allow for exceptions. Further, although CMS estimated the requirement would result in savings for the federal government and states of $90 million for fiscal year 2008, states' responses indicated that this estimate may be overstated for two reasons. Specifically, CMS did not account for the increased administrative expenditures reported by states, and the agency's estimated savings from ineligible, noncitizens no longer receiving benefits may be less than anticipated. In commenting on a draft of the report, CMS raised concerns about the conclusions drawn from the survey responses as to the requirement's effect on access, mainly that states did not submit data to support their responses.
GAO-07-889, Medicaid: States Reported That Citizenship Documentation Requirement Resulted in Enrollment Declines for Eligible Citizens and Posed Administrative Burdens
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Requirement Resulted in Enrollment Declines for Eligible Citizens and
Posed Administrative Burdens' which was released on July 25, 2007.
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
June 2007:
Medicaid:
States Reported That Citizenship Documentation Requirement Resulted in
Enrollment Declines for Eligible Citizens and Posed Administrative
Burdens:
GAO-07-889:
GAO Highlights:
Highlights of GAO-07-889, a report to congressional requesters
Why GAO Did This Study:
The Deficit Reduction Act of 2005 (DRA) included a provision that
requires states to obtain documentary evidence of U.S. citizenship or
nationality when determining eligibility of Medicaid applicants and
current beneficiaries; self-attestation of citizenship and nationality
is no longer acceptable. The Centers for Medicare & Medicaid Services
(CMS) issued regulations states must follow in obtaining this
documentation. Interested parties have raised concerns that efforts to
comply with the requirement will cause eligible citizens to lose access
to Medicaid coverage and will be costly for states to implement.
GAO was asked to examine how the requirement has affected individuals‘
access to Medicaid benefits and assess the administrative and fiscal
effects of implementing the requirement.
To do this work, GAO surveyed state Medicaid offices in the 50 states
and the District of Columbia about their perspectives on access issues
and the administrative and fiscal effects of the requirement. GAO
obtained complete responses from 44 states representing 71 percent of
national Medicaid enrollment in fiscal year 2004. GAO also reviewed
federal laws, regulations, and CMS guidance.
What GAO Found:
States reported that the citizenship documentation requirement resulted
in barriers to access to Medicaid for some eligible citizens. Twenty-
two of the 44 states reported declines in Medicaid enrollment due to
the requirement, and a majority of these states attributed the declines
to delays in or losses of Medicaid coverage for individuals who
appeared to be eligible citizens. Of the remaining states, 12 reported
that the requirement had no effect and 10 reported they did not know
the requirement‘s effect on enrollment. Not all of the 22 states
reporting declines could quantify enrollment declines due specifically
to the requirement, but a state that had begun tracking the effect
identified 18,000 individuals in the 7 months after implementation
whose applications were denied or coverage was terminated for inability
to provide the necessary documentation, though the state believed most
of them to be eligible citizens. Further, states reporting a decline in
enrollment varied in their impressions about the requirement‘s effect
on enrollment after the first year of implementation. States‘
enrollment policies and whether an individual was an applicant or a
beneficiary may have influenced the requirement‘s effect on access to
Medicaid. For example, states that relied primarily on mail-in
applications before the requirement were more likely to report declines
in enrollment than states where individuals usually applied in person.
In addition, the requirement may have more adversely affected
applicants than beneficiaries because applicants were given less time
to comply in some states and were not eligible for Medicaid benefits
until they documented their citizenship.
Although states reported investing resources to implement the
requirement, potential fiscal benefits for the federal government and
states are uncertain. All 44 states reported taking administrative
measures to implement the requirement and assist individuals with
compliance. In addition, 10 states reported that a total of $28 million
was appropriated in state fiscal year 2007, and 15 states budgeted
funds for implementation costs in state fiscal year 2008. Despite these
measures, states reported that the requirement has increased the level
of assistance needed by individuals and amount of time spent by states
during the enrollment process. States specified two aspects of the
requirement as increasing the burden for them and for individuals: that
documents had to be originals and the list of acceptable documents was
complex and did not allow for exceptions. Further, although CMS
estimated the requirement would result in savings for the federal
government and states of $90 million for fiscal year 2008, states‘
responses indicated that this estimate may be overstated for two
reasons. Specifically, CMS did not account for the increased
administrative expenditures reported by states, and the agency‘s
estimated savings from ineligible, noncitizens no longer receiving
benefits may be less than anticipated.
In commenting on a draft of the report, CMS raised concerns about the
conclusions drawn from the survey responses as to the requirement‘s
effect on access, mainly that states did not submit data to support
their responses.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-889].
To view the full product, including the scope and methodology, click on
the link above. For more information, contact James Cosgrove at (202)
512-7114 or cosgrovej@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Many States Reported That the Requirement Resulted in Delayed or Lost
Medicaid Coverage for Some Individuals Who Appeared to Be Eligible:
States Reported Investing Resources to Implement Requirement, with
Fiscal Benefits Uncertain:
Agency Comments and Our Evaluation:
Appendix I: List of Acceptable Documents for Proving Citizenship and
Identity, as Defined under Federal Regulations:
Appendix II: Comments from the Centers for Medicare & Medicaid
Services:
Appendix III: GAO Contact and Staff Acknowledgments:
Tables:
Table 1: Examples from the List of Acceptable Documents for Proving
Citizenship Defined under Federal Regulations, by Level of Reliability:
Table 2: Administrative Measures Frequently Taken by States to
Implement the Requirement and Assist Individuals with Compliance:
Table 3: Challenges Posed by Certain Aspects of the Requirement, as
Reported by States:
Table 4: List of Acceptable Documents for Proving Citizenship, as
Defined under Federal Regulations:
Table 5: Acceptable Documents for Proving Identity, as Defined under
Federal Regulations:
Figures:
Figure 1: Key Events in the Implementation of the Requirement:
Figure 2: Effect of the Requirement on Medicaid Enrollment, as Reported
by States:
Figure 3: Primary Reason Why Requirement Resulted in Medicaid
Enrollment Declines, as Reported by States:
Figure 4: Comparison of the Effect of the Requirement on a Pregnant
Woman Applying for Medicaid and a Pregnant Woman at Redetermination:
Figure 5: Effect of the Requirement on States' Level of Assistance and
Amount of Time Needed during Application and Redetermination:
Abbreviations:
CMS: Centers for Medicare & Medicaid Services:
DRA: Deficit Reduction Act of 2005:
FMAP: Federal Medical Assistance Percentage:
HHS: Department of Health and Human Services:
OIG: Office of Inspector General:
SSA: Social Security Administration:
TRHCA: Tax Relief and Health Care Act of 2006:
United States Government Accountability Office:
Washington, DC 20548:
June 28, 2007:
The Honorable John D. Dingell:
Chairman:
Committee on Energy and Commerce:
House of Representatives:
The Honorable Henry A. Waxman:
Chairman:
Committee on Oversight and Government Reform:
House of Representatives:
In recent years, states have focused on efforts to streamline and
simplify the application and eligibility determination processes for
Medicaid, the joint federal-state health care financing program that in
fiscal year 2004 covered nearly 60 million low-income individuals,
including children, families, and individuals who are elderly or
disabled. For example, many states have made application and enrollment
processes more accessible through mail-in applications. Some states
have also simplified application processes by minimizing documentation
requirements, permitting self-declaration of income, and automating
systems. These streamlined processes were part of an effort to increase
enrollment of eligible individuals in the program.
The Deficit Reduction Act of 2005 (DRA), which was enacted on February
8, 2006, contains many changes to Medicaid requirements, at least one
of which affects states' abilities to streamline certain program
operations.[Footnote 1] Specifically, in addition to changes related to
benefits, cost-sharing, provider payment, and program integrity, the
DRA includes a provision that requires states to obtain satisfactory
documentary evidence of U.S. citizenship or nationality[Footnote 2] for
nearly 40 million nonexempt Medicaid beneficiaries within 1 year of the
provision's July 1, 2006, effective date, as well as for new applicants
to the program, who constitute an estimated 10 million individuals
annually.[Footnote 3] While U.S. citizenship or satisfactory
immigration status has long been a requirement for Medicaid
eligibility, individuals in most states could previously attest, under
penalty of perjury, to their citizenship status in writing. Self-
attestation of citizenship is no longer acceptable.[Footnote 4]
Instead, the DRA requires that states implement an effective process
for documenting citizenship in order to obtain federal Medicaid
matching funds. Although the DRA did not provide any additional federal
funds for costs associated with complying with this requirement, states
may seek federal matching funds for such administrative expenditures.
In implementing the DRA provision, the Centers for Medicare & Medicaid
Services (CMS)[Footnote 5] issued an interim final rule that outlines a
prescriptive process states must follow to obtain satisfactory
documentation of citizenship for Medicaid applicants and existing
beneficiaries and identifies a list of acceptable
documentation.[Footnote 6] Five months after the DRA provision took
effect, the Tax Relief and Health Care Act of 2006 was enacted, which
exempted additional populations from documenting citizenship, such as
children in foster care.[Footnote 7]
Interested parties, including states and advocacy organizations, have
raised concerns about the requirement, such as stating that the need
for the requirement had not been established,[Footnote 8] that efforts
to comply with the requirement will result in eligible citizens losing
access to Medicaid coverage, and that it will be costly for states and
individuals. You asked us to evaluate the effect of the requirement on
eligible individuals' access to the Medicaid program and the
administrative and fiscal burden the requirement imposed on
individuals, states, and the federal government. For this report, we
(1) examined how the requirement has affected individuals' access to
Medicaid benefits and (2) assessed the administrative and fiscal
effects of implementing the requirement.
To conduct our work, we surveyed state Medicaid offices in the 50
states and the District of Columbia about the effects of the
requirement and obtained responses from 96 percent of them (49 of
51).[Footnote 9] Of the 49 responses, 1 state's response was largely
incomplete and 4 states reported they had not implemented the
requirement as of January 2007,[Footnote 10] so we excluded those 5
states from our analysis, leaving 44 usable responses.[Footnote 11]
States submitted responses in March and April 2007. With regard to the
effects on individuals' access to Medicaid benefits, we asked states
for their perspectives about (1) changes in enrollment as a result of
the requirement, (2) the reasons for any enrollment declines,[Footnote
12] (3) the groups most affected, and (4) expectations of how long
reported changes would continue. We also asked about state policies
regarding the amount of time states allow individuals to comply with
the requirement before denying coverage or terminating enrollment. With
regard to the administrative and fiscal effects of the requirement, we
asked states about (1) measures taken to implement the requirement and
assist individuals with compliance, (2) changes in the number of
individuals needing assistance during the eligibility determination
process and the amount of time necessary for states to make eligibility
determinations after implementing the requirement, (3) the average
number of pending and completed eligibility determinations before and
after implementing the requirement, (4) the challenges they and
individuals faced in meeting the requirement, and (5) the budget
implications of the requirement in state fiscal years 2007 through
2010.[Footnote 13] We did not independently validate the trends or the
data states provided. The results of our survey represent only the
views of the 44 state Medicaid offices that completed it.
In assessing the administrative and fiscal effects of the requirement,
we also reviewed federal laws, regulations, and CMS guidance to states
related to the requirement, and compared the requirement with
citizenship documentation requirements applied by other federal
agencies, including the Social Security Administration (SSA). In
addition, we interviewed CMS officials regarding certain aspects of the
requirement. We also obtained CMS's estimates of the administrative and
fiscal effects of the requirement on states and the federal government.
We performed our work from November 2006 through June 2007 in
accordance with generally accepted government auditing standards.
Results in Brief:
States reported that the requirement resulted in barriers to access to
Medicaid, such as delayed or lost coverage for some eligible
individuals. Twenty-two of the 44 states reported declines in Medicaid
enrollment due to the requirement, and a majority of these states
attributed the enrollment declines to delays in or losses of Medicaid
coverage for individuals who appeared to be eligible citizens. Of the
remaining states, 12 reported that the requirement had no effect on
enrollment, and 10 reported that they did not know the effect of the
requirement on enrollment. Not all of the 22 states reporting
enrollment declines as a result of the requirement could quantify the
decline. One that had begun tracking the effect, however, identified
18,000 individuals in the first 7 months of implementing the
requirement whose applications were denied or who had coverage
terminated due to the inability to provide the necessary documentation,
though the state generally believed them to be eligible citizens.
States that reported a decline in enrollment varied in their
impressions of the effects of the requirement on enrollment beyond the
first year of implementation. The effect of the requirement on
individuals' access to Medicaid could have been influenced by state
enrollment policies and whether an individual was an applicant or an
existing beneficiary. For example, states that relied primarily on mail-
in applications prior to implementing the requirement were more likely
to report declines in enrollment than were states where individuals
most frequently applied in person. In addition, the requirement may
affect Medicaid applicants more adversely than beneficiaries because
applicants in some states were given less time to comply and were not
eligible for Medicaid benefits until they documented their citizenship.
Although states have invested resources to implement the requirement,
potential fiscal benefits for the federal government and states are
uncertain. All of the 44 states reported taking a number of
administrative measures, such as training eligibility workers and
hiring additional staff, to implement the requirement and assist
individuals with compliance. In addition, 10 states reported that a
total of $28 million was appropriated for the requirement in state
fiscal year 2007, and 15 states budgeted funds for state fiscal year
2008. Despite these measures, states reported that the requirement
resulted in the state spending more time completing applications and
redeterminations and individuals needing more assistance in person
during the process. States reported that two aspects of the requirement
increased the burden of the requirement on individuals and states,
namely (1) that documents must be originals and (2) the list of
acceptable documents was complex and did not allow for exceptions. For
example, states reported that individuals who previously would have
applied for Medicaid through the mail will not part with original
documents, such as driver's licenses, and are instead presenting them
in person, which has increased the workload of states' eligibility
workers. CMS officials noted, however, that the agency took a number of
steps to minimize the administrative burden of the requirement,
including substantially expanding the list of acceptable documentation
beyond what was included in the DRA provision. In addition to the
ongoing challenges to states and individuals, federal estimates of the
financial benefits of the requirement for the federal government and
states may be overstated. CMS estimated the requirement would result in
savings of $50 million for the federal government and $40 million for
states in fiscal year 2008 as a result of terminations of eligibility
for noncitizens inappropriately receiving Medicaid benefits. State
responses indicated, however, that CMS's estimate of savings may be
overstated because the estimate did not account for the increases in
administrative expenditures reported by states and the intended effect
of the requirement--to prevent ineligible noncitizens from receiving
Medicaid benefits--may be less prevalent than CMS expected. For
example, among the states that reported expecting the requirement to
result in a decrease in Medicaid expenditures, only one state reported
potential savings as a result of individuals being denied or terminated
from coverage who were determined ineligible because of their
citizenship status.
In commenting on a draft of this report, CMS raised concerns about the
sufficiency of the underlying data and made several comments about our
findings on the administrative and fiscal effects of the requirement.
In particular, CMS expressed concern that the report overstated the
significance of states' reports of declines in enrollment due to the
requirement and the challenges that states and individuals faced in
complying with it. CMS nevertheless agreed the requirement posed
challenges for individuals and states, though the agency stated that it
believed these challenges had decreased and would continue to do so.
Our findings represent the views of state Medicaid offices, which
stated that the requirement has resulted in enrollment declines and has
posed administrative burdens to states and individuals. Further, our
survey results indicate that the effects states experienced in the
first year may continue at least to some extent in the future.
Background:
Medicaid programs generally represent an open-ended entitlement under
which the federal government is obligated to pay its share of
expenditures for covered services provided to eligible individuals
under each state's federally approved Medicaid plan.[Footnote 14] Under
federal Medicaid law, to qualify for Medicaid coverage, individuals
generally must fall within certain eligibility categories--such as
children, pregnant women, adults in families with dependent children,
and those who are aged or disabled--and meet financial eligibility
criteria.[Footnote 15] In addition, since 1986, federal law has
required that, as a condition of Medicaid eligibility, individuals
declare under penalty of perjury that they are citizens or nationals of
the United States or in satisfactory immigration status.[Footnote 16]
Eligibility is determined at the time of application, and for
individuals enrolled in the program, at a regular basis referred to as
redetermination.[Footnote 17]
States differ in how they determine eligibility for Medicaid, and many
took steps before 2006 to streamline their enrollment processes. While
some states conduct all eligibility screening and determinations within
the state's Medicaid agency, other states contract with different state
agencies, counties, or other local governmental entities to conduct or
assist with eligibility determinations. In some cases, states also
utilize community-based organizations to assist with outreach and
education in their Medicaid programs. Over the past decade, states have
also made efforts to simplify the application process to make Medicaid
programs more accessible to eligible families. As part of these
efforts, many states implemented mail-in applications and ended
requirements for face-to-face interviews. States also began
coordinating Medicaid eligibility determinations with other public
programs, such as school lunch programs and Temporary Assistance for
Needy Families.
Enacted in February 2006, the DRA includes a number of new requirements
for state Medicaid programs.[Footnote 18] Most relevant to this report,
as of July 1, 2006, the DRA required states to document citizenship of
applicants and beneficiaries as a condition of receiving federal
matching funds for their Medicaid expenditures.[Footnote 19] Under this
provision, Medicaid applicants and beneficiaries who are undergoing
redeterminations of eligibility must provide "satisfactory documentary
evidence" of citizenship.[Footnote 20] Documenting citizenship is a
onetime event completed by individuals either at application or, for
those already enrolled, at their first redetermination of eligibility.
(Fig. 1 illustrates the sequence of key events regarding the
requirement from enactment of the DRA through February 2007.)
Figure 1: Key Events in the Implementation of the Requirement:
[See PDF for image]
Source: GAO.
[End of figure]
The DRA explicitly exempts certain individuals from having to document
citizenship, specifically those entitled to or enrolled in Medicare,
certain individuals receiving Supplemental Security Income, and any
additional populations as designated by the Secretary of HHS.[Footnote
21] In December 2006, Congress expanded the list of populations that
are exempt, adding individuals receiving Social Security disability
insurance benefits and children in foster care or children who are
receiving adoption or foster care assistance.[Footnote 22]
In implementing the DRA provision, CMS first provided guidance to
states in a June 2006 letter to state Medicaid directors and
subsequently published an interim final rule on July 12, 2006, almost 2
weeks after the DRA provision went into effect.[Footnote 23] In the
interim final rule, CMS expanded upon the list of acceptable documents
identified in the DRA and published regulations that grouped the
documents by level of reliability, creating a hierarchy in the list and
restricting the use of less reliable documents.
As required under the DRA, certain documents, such as U.S. passports,
are considered sufficient evidence of citizenship. The DRA requires
that if an individual does not have one of these primary documents, the
individual must produce specific types of documentation establishing
citizenship, such as a U.S. birth certificate, as well as documentation
establishing personal identity. The regulations published by CMS
similarly identify primary, or tier 1, documents to establish
citizenship. Under the regulations, if individuals do not have primary
evidence, they are expected to produce secondary, or tier 2, evidence
of citizenship, such as a military record showing a U.S. place of
birth, as well as evidence of identity, such as a state-issued driver's
license. If neither primary nor secondary evidence of citizenship is
available, individuals may provide third tier evidence of citizenship
to accompany evidence of identity. If primary evidence of citizenship
is unavailable, secondary and third tier evidence do not exist or
cannot be obtained in a reasonable time period, and the individual was
born in the United States, then the individual may provide fourth tier
evidence of citizenship, along with evidence of identity. (See table 1
and app. I.)
Table 1: Examples from the List of Acceptable Documents for Proving
Citizenship Defined under Federal Regulations, by Level of Reliability:
Level of documentation: Tier 1 (most reliable);
Examples of acceptable documents:
* U.S. passport[A];
* Certificate of naturalization[A];
* Certificate of citizenship[A];
Other documents required: None.
Level of documentation: Tier 2;
Examples of acceptable documents:
* U.S. birth certificate[B];
* Report of birth abroad of a U.S. citizen[B];
* U.S. citizen I.D. card issued by the Immigration and Naturalization
Service[B];
* Final adoption decree showing the child's name and U.S. birthplace;
* U.S. military record showing U.S. place of birth;
Other documents required: Verification of identity[C].
Level of documentation: Tier 3;
Examples of acceptable documents:
* Hospital record showing a U.S. place of birth;
* Health insurance record showing a U.S. place of birth;
Other documents required: Verification of identity[C].
Level of documentation: Tier 4 (least reliable);
Examples of acceptable documents:
* Federal or state census record showing U.S. citizenship or place of
birth;
* Nursing home admission papers showing a U.S. place of birth;
* U.S. vital statistics official notice of birth registration;
Other documents required: Verification of identity[C].
Source: GAO analysis of the DRA and regulations published by CMS.
Notes: This table is not a comprehensive list of documents CMS
considers reliable evidence of citizenship. Further, the table does not
detail CMS's restrictions for using particular documents. For example,
in tier 2, a U.S. birth certificate must be issued before the
individual turned 5 years of age. In tier 3, hospital records must be
on hospital letterhead and created at least 5 years before the date of
the individual's application for Medicaid. Appendix I provides a more
complete list of documents and accompanying restrictions as well as a
list of acceptable documents for verifying identity.
[A] Under the DRA, this document was determined to be satisfactory
evidence of citizenship.
[B] Under the DRA, this document was determined to be satisfactory
evidence of citizenship when accompanied by documentation of identity.
[C] Acceptable evidence of identity includes such documents as driver's
licenses, school identification cards, and, for children under 16,
school records.
[End of table]
In addition to prescribing a list of acceptable documents for verifying
citizenship, the regulations issued by CMS specify, with one exception,
that documents must be originals or copies certified by the issuing
agency. The exception is that for a U.S. birth certificate, which is a
tier 2 document, states may use a cross match with a state vital
statistics agency to document a birth record. The regulations allow
states to accept original documentation from individuals in person or
through the mail.
Under the regulations issued by CMS, states must provide applicants and
Medicaid beneficiaries a "reasonable opportunity" to document their
citizenship before denying or terminating Medicaid eligibility. States
have flexibility in defining the length of the reasonable opportunity
period. The regulations further explain that current Medicaid
beneficiaries must remain eligible for benefits during this period but
that states may terminate eligibility afterward if they determine that
the beneficiary has not made a good faith effort to present
documentation. In contrast, applicants are not eligible for Medicaid
coverage until they submit the required documentation. The regulations
also require states to assist individuals who are physically or
mentally incapable of obtaining documentation and do not have a
representative to assist them. However, the regulations do not specify
criteria for determining who is capable or the level of assistance
states should provide. CMS intends to monitor state implementation of
the requirement, including the extent to which states use the most
reliable evidence available to establish citizenship based on its
hierarchy. States that do not comply with the regulations may face
either denied or deferred payment of federal matching funds.
In the interim final rule, CMS assessed potential administrative and
fiscal effects of the requirement. For example, CMS estimated that
individuals would need, on average, 10 minutes to acquire and provide
the state with acceptable documentary evidence and that states would
need 5 minutes per individual to verify citizenship and maintain
current records.[Footnote 24] In addition, CMS determined that
implementing the rule would have no consequential effect on costs for
state, local, or tribal governments or the private sector.[Footnote 25]
Under the rule, states may seek federal Medicaid matching funds for
administrative expenditures associated with implementing the
requirement at a 50 percent federal matching rate.
Many States Reported That the Requirement Resulted in Delayed or Lost
Medicaid Coverage for Some Individuals Who Appeared to Be Eligible:
States reported that the requirement resulted in barriers to access,
such as delayed or lost Medicaid coverage for some eligible
individuals. Of the 44 states, 22 reported a decline in Medicaid
enrollment due to the requirement. Most that reported a decline in
enrollment attributed it to delays in or losses of coverage for
individuals who appeared to be eligible citizens, and all states
reporting a decline reported that children were affected by the
requirement. States that reported a decline in enrollment varied in
their views of the effects on access to Medicaid coverage after the
first year of implementation. State enrollment policies and whether an
individual is an applicant or a beneficiary at redetermination are two
factors that may have influenced the effect of the requirement on
individuals' access.
States Reported Enrollment Declines Largely Driven by Delays in or
Losses of Medicaid Coverage for Eligible Citizens:
Half the states that reported implementing the requirement noted that
the requirement resulted in declines in Medicaid enrollment.[Footnote
26] Of the 44 states, 22 states reported a decline in enrollment due to
implementing the requirement, 12 reported no change in enrollment as a
result of the requirement, and 10 reported that they did not know the
effect of the requirement on enrollment (see fig. 1). Of the 22 states
that reported a decline in enrollment due to the requirement, all
responded that children were affected by the requirement, and 21
reported that adults were affected, with 2 specifying pregnant women. A
few also responded that the aged and blind and disabled were also
affected.
Figure 2: Effect of the Requirement on Medicaid Enrollment, as Reported
by States:
[See PDF for image]
Source: GAO survey of state Medicaid offices.
Note: Numbers reflect responses from 44 states.
[End of figure]
Though states often cited a combination of reasons for the decline in
Medicaid enrollment, when asked the primary reason, the majority of
states (12 of 22) reported that enrollment declined because applicants
who appeared to be eligible citizens experienced delays in receiving
coverage. In addition, 5 of the 22 states identified the primary reason
for the enrollment decline as current beneficiaries losing coverage,
with 4 of the 5 states reporting that those individuals appeared
eligible. Two states reported that declines were largely driven by
denials in coverage for individuals who did not prove their
citizenship. It was unclear from survey results, however, whether these
individuals were determined ineligible because they were not citizens
or simply because they did not provide the required documents within
the time frames allowed by the state. (See fig. 3.) Two of the
remaining 3 states reported that the primary reason for the decline was
that individuals were discouraged from applying because of the
requirement or were not responding to states' requests for
documentation of citizenship.[Footnote 27]
Figure 3: Primary Reason Why Requirement Resulted in Medicaid
Enrollment Declines, as Reported by States:
[See PDF for image]
Source: GAO survey of state Medicaid offices.
Notes: Numbers do not sum to 22, the number of states reporting a
decline in Medicaid enrollment as a result of implementing the
requirement, because 2 states reported other reasons, namely that
individuals were discouraged from applying or were not responding to
states' requests for the documentation, and 1 state did not answer the
relevant survey question.
[A] It is unclear from the survey results whether these individuals
lost or were denied coverage because they were not citizens or because
they did not provide the required documentation.
[End of figure]
The extent of the decline in Medicaid enrollment due to the requirement
in some individual states or nationally was unknown because not all
states track the effect of the requirement on enrollment. However, 1
state that had begun tracking the effect reported (1) denying an
average of 15.6 percent of its monthly applications because of
insufficient citizenship documentation in the first 7 months following
implementation and (2) terminating eligibility for an average of 3.2
percent of beneficiaries at redetermination per month over the same
period and for the same reason. Overall, these denials and terminations
represented over 18,000 individuals, who the state generally believed
were eligible citizens.[Footnote 28] While not tracking the effect of
the requirement on enrollment explicitly, 10 other states that
attributed enrollment declines at least in part to applicants who were
delayed or denied coverage also reported increases in monthly denials
ranging from 1 to 14 percent after implementing the requirement.
States reporting a decline in Medicaid enrollment differed in their
views of the effects of the requirement on enrollment after the first
year of implementation. Of the 22 states that reported a decline in
enrollment, 17 states responded that they expected the downward
enrollment trend to continue. Five of these states indicated that the
declines would level off within approximately 1 year of implementation,
citing, for example, a drop-off in terminations once their current
beneficiaries have successfully documented their citizenship. Ten of
the 17 states reported that they were unsure how long enrollment
declines would continue or generally expected the trend to continue
indefinitely.[Footnote 29] A few of these states noted concern about
the ongoing effect on new applicants who will be unfamiliar with the
requirement and may be denied enrollment or discouraged from applying.
The remaining 5 of 22 states reported that they did not expect the
decline to continue.[Footnote 30]
State Enrollment Policies and Individuals' Enrollment Status May Have
Influenced Effect of Requirement on Access to Medicaid:
Variation in the effects of the requirement on individuals' access may
have resulted from different state enrollment policies. For example,
states that reported a previous reliance on mail-in applications and
redeterminations were more likely to report a decline in Medicaid
enrollment. About two-thirds of the 22 states that reported a decline
in enrollment indicated that individuals most commonly applied by mail
before the requirement was implemented. In contrast, the majority of
the 12 states that reported no change in enrollment reported that
individuals most frequently applied in person before the requirement
was implemented. In addition, prior to implementation, 6 states had
documentation policies in place that were similar to the requirement.
Three of these 6 states reported no change in enrollment, with 1
explaining that it was because the state already required (1) proof of
birth to verify age and family relationship and (2) proof of identity
for adults. Two of the 6 states reported a decline in enrollment caused
by the requirement.[Footnote 31]
Another enrollment policy that may have influenced the requirement's
effect on access to Medicaid coverage was the amount of time states
allowed individuals to comply with the requirement--otherwise known as
reasonable opportunity periods. In total, 33 states reported the number
of days they allowed applicants and beneficiaries to meet the
requirement before denying applications or terminating eligibility,
with limits generally ranging from 10 days to 1 year. Nine of the 33
states reported allowing applicants 30 days or less, and 4 of these
states also reported a decline in enrollment due to the
requirement.[Footnote 32] A few states reported allowing applicants and
beneficiaries an indefinite amount of time to obtain and submit the
necessary documentation, provided they were deemed as making a good
faith effort. Some states' written policies indicated that the
reasonable opportunity period could be extended, provided the
individual notified the state that he or she was making a good faith
effort to obtain the documentation but needed more time.[Footnote 33]
The effect of the requirement on access may have also depended on
whether the individual was a new applicant or a beneficiary at
redetermination. Applicants who declare themselves citizens are not
eligible for Medicaid coverage until they submit the required
documentation, while beneficiaries at redetermination maintain their
eligibility while collecting documents as long as they are within the
reasonable opportunity period allowed by the state or deemed as making
a good faith effort to comply with the requirement. For example, a
pregnant woman at redetermination is eligible to have her 20-week
ultrasound covered by Medicaid, even though she has not yet submitted
her documentation to the state. In contrast, a pregnant woman who is a
new Medicaid applicant would not be determined eligible for coverage
until she submits her documentation (see fig. 4).[Footnote 34] In
addition, applicants who were born out of state may have faced
additional delays while attempting to obtain documentation from their
birth state. For example, one state noted that it could take 6 months
or more to obtain a birth certificate from another state.
Figure 4: Comparison of the Effect of the Requirement on a Pregnant
Woman Applying for Medicaid and a Pregnant Woman at Redetermination:
[See PDF for image]
Source: GAO.
[End of figure]
In addition, applicants in some states were given less time than
beneficiaries to meet the requirement. Of the 33 states that provided
information on their reasonable opportunity periods, 13 states reported
that the time allowed for providing documentation was longer for
beneficiaries at redetermination than for applicants, with this
difference ranging from 24 to 320 days. Five of the 13 states reported
allowing 45 days for applicants and 300 days or more for beneficiaries.
States may offer more flexibility to Medicaid beneficiaries as CMS
officials told us that for these individuals the state cannot terminate
benefits without documenting that the beneficiary has not made a good
faith effort to provide the necessary documentation.
States Reported Investing Resources to Implement Requirement, with
Fiscal Benefits Uncertain:
Although states reported investing resources to implement the
requirement, potential fiscal benefits for the federal government and
states are uncertain. To implement the requirement and assist
individuals with compliance, all of the 44 states took a number of
administrative measures, such as providing additional training for
eligibility workers and hiring additional staff, and some also reported
committing financial resources. Despite these measures, however, states
reported that as a result of the requirement, individuals needed more
assistance in person and it was taking the state longer on average to
complete applications and redeterminations. According to states, two
particular aspects of the requirement increased the burden of
implementing it: (1) that documents must be originals and (2) the list
of acceptable documents was complex and did not allow for exceptions.
While CMS estimated federal and state savings from the requirement, the
estimates may be overstated.
State Resources Invested to Implement the Requirement and Assist
Individuals with Compliance:
All 44 states reported taking a number of administrative measures to
implement the requirement and assist individuals with compliance.
Measures most frequently taken by states included training eligibility
workers, revising application and redetermination forms, conducting
vital statistics data matches, and modifying information technology
systems. For example, 1 state reported that in addition to training
18,000 staff on the requirement, it also provided training and
information to community agencies, consumer advocates, and providers on
how to assist individuals with compliance. Another state established
data matches with Indian Health Services to obtain hospital records
that met the requirement and built a Web site on which eligibility
workers could search the state's vital records to document citizenship.
To supplement the efforts of eligibility workers, 3 states reported
having formed special units of staff focused entirely on assisting
individuals to meet the requirement, particularly in difficult cases
where eligibility workers had been unsuccessful in their attempts to
help individuals comply. One of those states reported that it was in
the process of expanding the size of its team from 22 workers to 40
workers. Table 2 lists the administrative measures frequently reported
by states.
Table 2: Administrative Measures Frequently Taken by States to
Implement the Requirement and Assist Individuals with Compliance:
Measures taken by states: Conducted additional training for eligibility
workers;
Number of states (of 44): 39.
Measures taken by states: Revised application and redetermination
forms;
Number of states (of 44): 33.
Measures taken by states: Conducted data matches with the state's vital
statistics agency;
Number of states (of 44): 33.
Measures taken by states: Modified information technology systems;
Number of states (of 44): 32.
Measures taken by states: Conducted educational outreach to
individuals;
Number of states (of 44): 32.
Measures taken by states: Assisted individuals in paying for documents;
Number of states (of 44): 18.
Measures taken by states: Hired or allocated additional staff;
Number of states (of 44): 15.
Measures taken by states: Authorized overtime pay;
Number of states (of 44): 11.
Measures taken by states: Added new application and redetermination
methods;
Number of states (of 44): 9.
Measures taken by states: Increased third-party administrative
contracts;
Number of states (of 44): 7.
Source: GAO survey of state Medicaid offices.
[End of table]
Beyond these administrative measures, 40 percent of the 44 states
reported having appropriated funds for implementation or planned to do
so in future years. Specifically, 12 states reported that funds were
appropriated in their state fiscal year 2007 to implement the
requirement, which for the 10 states that specified the amount totaled
over $28 million, with appropriations ranging from $350,000 to $10
million in individual states.[Footnote 35] Further, 15 states budgeted
funds for implementation costs in state fiscal year 2008.[Footnote 36]
While many states did not specifically appropriate funds toward
implementing the requirement in state fiscal year 2007, this may have
been due, in part, to the timing of the requirement within the budget
year. States may not be budgeting funds for future years for various
reasons, including that the burden of the requirement may decrease
after the first year of implementation or that the state may face other
budget constraints. For example, one state Medicaid office that
reported a significant backlog in applications and redeterminations as
a result of the requirement requested funds for implementation in state
fiscal year 2008 and planned to renew those requests in state fiscal
years 2009 and 2010, but was not sure whether the state legislature
would appropriate the funds.
Two Aspects of the Requirement Increased the Burden of Implementation:
Despite investments of resources, most states reported that the
requirement resulted in the state spending more time completing
applications and redeterminations and individuals needing more
assistance in person during the process. Of the 44 states, 28 states
reported increases in the level of assistance provided to clients in
person, and 35 states reported an increase in the amount of time it
took the state to complete applications and redeterminations. (See fig.
5.) States reporting no change in the level of in-person assistance or
time spent completing applications and redeterminations since
implementation were frequently states where individuals primarily
applied for and renewed Medicaid enrollment in person prior to the
requirement.
Figure 5: Effect of the Requirement on States' Level of Assistance and
Amount of Time Needed during Application and Redetermination:
[See PDF for image]
Source: GAO survey of state Medicaid offices.
Notes: Numbers do not sum to 44 for level of assistance, because 1
state reported that the amount of in-person assistance increased for
applications but did not change for redeterminations and therefore was
not counted, and another state did not answer the question related to
assistance provided in person. For changes in time spent by the state
per application and redetermination, numbers do not sum to 44 because 1
state did not answer the related question.
[End of figure]
Of the 35 states that reported increases in enrollment processing time,
most reported that the requirement added 5 or more minutes per case to
the processing time for applications and redeterminations. While only 1
of the 35 states expected an increase of less than 5 minutes per case,
9 states estimated an additional 5 to 15 minutes per case, and 16
states expected the requirement to add over 15 minutes of processing
time per application or redetermination, well above the 5 minutes
estimated by CMS in the interim final rule.[Footnote 37] One of these
16 states reported processing an average of over 150,000 applications
per month in the 8 months following implementation. In that state,
assuming an increase in processing time of a minimum of 16 minutes per
application since implementing the requirement, this would have added
at least 40,000 hours of staff time per month. Other states emphasized
that the effect of the requirement on workload goes beyond the amount
of time necessary to complete applications and redeterminations. For
example, one state reported a 60 percent increase in phone calls (from
24,000 to 39,000 per month), a tenfold increase in voice messages (from
1,200 to 11,000 per month), and an 11 percent increase in the amount of
time spent on each call.[Footnote 38]
Though the requirement represented a change in enrollment procedures
for most states, states reported that certain aspects of the
requirement specified under federal regulations by CMS increased their
implementation burden. More than 80 percent of states (36 of 44)
reported facing administrative challenges in implementing the
requirement, and many attributed the challenges to two specific aspects
of the requirement outlined in the regulations, namely (1) that
documents must be originals and (2) that the list of acceptable
documentation was complex and did not allow for exceptions. In fact,
nearly all states (42 of the 44) reported that having to provide
original documentation posed a barrier to eligible citizens' meeting
the requirement. Further, many states also reported that mandating
originals affected state workload primarily because individuals did not
feel comfortable mailing the documents to the state and instead began
presenting them in person. With regard to the list of acceptable
documents, states reported that the list was complex, often confusing
both individuals and eligibility workers, and left states with no
discretion to allow exceptions. For example, 1 state that documented
citizenship for Medicaid prior to enactment of the DRA noted that when
acceptable documentation was not available, the state made an
assessment based on a preponderance of evidence, which included certain
tribal documents excluded from CMS's list. Thirty-four states reported
that an individual's inability to provide documents other than those
defined under federal regulations by CMS created a barrier to
individuals' compliance with the requirement. Table 3 presents some of
the challenges reported by states to implement the requirement.
Table 3: Challenges Posed by Certain Aspects of the Requirement, as
Reported by States:
Aspect of requirement: Documents must be originals;
Challenge posed: Cost of obtaining original documents;
Description: Low-income families enrolled in Medicaid often cannot
afford to pay for original documents such as birth certificates, which
can cost up to $30 each. When individuals are physically or mentally
incapable of obtaining documents for themselves, doing so becomes the
state's responsibility, the cost of which has raised concerns among
several states.
Aspect of requirement: Documents must be originals;
Challenge posed: Original documents needed for daily living;
Description: Individuals cannot part with such documents as driver's
licenses for the number of days it would take to mail them and have
them returned by the state and do not want to risk identity theft. As a
result, more individuals are submitting the documents in person, which
has increased the volume of walk-in clients at eligibility offices. In
some rural areas, individuals may have to travel significant distances
to reach the nearest eligibility office to present the documents in
person.
Aspect of requirement: Documents must be originals;
Challenge posed: Management and remittance of original documents;
Description: Some individuals are choosing to submit driver's licenses
and U.S. passports through the mail, causing stress among eligibility
workers who want to return the documents as quickly as possible. In
addition, returning the documents can increase state mail costs.
Aspect of requirement: Prescribed list of acceptable documents;
Challenge posed: Complexity of list;
Description: The complexity of the tiered list of acceptable documents
has confused individuals and local eligibility workers. As a result,
states have invested more time answering calls from customers and
providing technical assistance to local offices.
Aspect of requirement: Prescribed list of acceptable documents;
Challenge posed: Lack of state discretion to allow exceptions;
Description: The list lacks flexibility for states to allow exceptions
when an individual, or the state on the individual's behalf, cannot
obtain any of the documents.
Source: GAO survey of state Medicaid offices.
[End of table]
When developing its interim final rule, CMS officials said that CMS
considered the specifications of the DRA and other existing federal
policies on documenting citizenship, including policies of SSA. CMS
officials told us that after meeting the specifications of the DRA, the
agency modeled its regulations after the policy established by SSA for
documenting citizenship when individuals apply for a Social Security
number. Specifically, SSA's policy mandates that documents be originals
and includes a hierarchy of documents with restrictions on the use of
less reliable documents. Also, the list of acceptable documents
identified by CMS mirrors SSA's list with only a few exceptions. In
contrast, however, SSA's policy allows more flexibility in special
cases. For example, when a U.S.-born applicant for a Social Security
number does not have any of the documents from the list, SSA's policy
allows staff to work with their supervisors to determine what would be
acceptable in those cases. CMS officials told us that CMS's list of
acceptable documents represents a significant expansion of what was
included in the DRA provision and is exhaustive and that they were not
aware of any case where an individual was unable to provide any
document from the list.
To assist states and individuals in complying with documenting
citizenship, CMS included some important tools in the regulations. For
example, the regulations allow states to use data matches with state
vital statistics agencies to verify citizenship and with other
government agencies to verify identity, which could alleviate the need
for individuals to submit original documents. While many states
reported conducting data matches on behalf of individuals, several also
expressed concerns that such matches required additional resources and
could not be done for individuals born out of state. One state reported
conducting 60,000 on-line inquiries per month into the state's vital
records system after implementing the requirement. In one area of the
state, however, nearly all children were born across state lines and
therefore the state could not electronically verify their citizenship.
The state reported that verifying citizenship for children in that
portion of the state was especially difficult. While CMS officials
confirmed that there is no nationwide database for verifying
citizenship, they also told us that there are currently initiatives
under way in more than one state to share vital statistics with other
states through data matches.[Footnote 39]
Estimates of Federal and State Fiscal Benefits May Be Overstated:
Though CMS expected some savings to result from the requirement in
fiscal year 2008, the estimate did not account for the cost to states
and the federal government to implement the requirement. CMS's Office
of the Actuary estimated that the requirement would result in $50
million in savings for the federal government and $40 million in
savings for states in fiscal year 2008, with all savings resulting from
terminations of eligibility for individuals who were not citizens.
Specifically, CMS assumed that 50,000 noncitizen beneficiaries (which
represent less than 1 percent of Medicaid enrollment nationwide) would
prove ineligible for Medicaid benefits and be terminated from the
program. Though CMS authorized states to claim federal Medicaid
matching funds for administrative expenditures related to implementing
the requirement, and 15 states reported budgeting funds for 2008 in
addition to the numerous other measures being taken by states, CMS's
estimate of savings did not account for any increase in administrative
expenditures by states or the federal government. CMS expected,
however, that states would experience higher administrative costs
during the first year of implementation with these costs decreasing in
later years.
In addition to not accounting for the cost of the requirement, survey
results indicated that CMS may have overestimated the potential savings
from the requirement because the intended effect of the requirement,
that is, to prevent ineligible noncitizens from receiving Medicaid
benefits, may be less prevalent than expected. When asked about
potential savings from the requirement, only 5 of the 44 states
reported expecting the requirement to result in a decrease in their
expenditures for Medicaid benefits in state fiscal year 2008, due in
large part to individuals who appeared to be eligible citizens who
experienced delays in or lost coverage. Only 1 of the 5 states
expecting savings reported that enrollment declines resulted in part
from denials or terminations of Medicaid coverage for individuals who
were determined ineligible because of their citizenship status. The
remaining 39 states expected no savings (20 states) or reported that it
was too early to know (19 states). Several of the 20 states that
expected no savings in 2008 reported that though some individuals have
experienced delays in coverage, those individuals were eligible
citizens and would eventually provide the required documentation and
receive coverage. In addition, 2 of these 20 states noted that they
were not inappropriately financing Medicaid benefits for noncitizens in
the past and so expected no savings. Of the 19 states that were unsure
how the requirement would affect expenditures, 2 were still tracking
the effects of the requirement. Another of these 19 states--a state
that reported a decline in enrollment as a result of implementing the
requirement--noted that it was difficult to determine whether it would
result in lower costs or whether costs would increase, as the state
expected individuals would wait to enroll until they were ill or
injured, rather than receive preventive care that is less costly to
provide.
Agency Comments and Our Evaluation:
We provided a draft of this report to CMS for comment and received a
written response, which is included in this report as appendix II. CMS
also provided technical corrections, which we incorporated as
appropriate. CMS commented that it generally did not disagree with the
approach of our study, but raised several concerns regarding the
sufficiency of the underlying data for, and certain aspects of, our
findings. In particular, CMS characterized the report's conclusions as
overstating the effect of the requirement on enrollment, and stated it
had concerns about the fact that the states did not submit data to
substantiate their responses to the survey questions on which we based
our findings. CMS also commented on our findings related to the
challenges posed by the requirement for states and individuals and the
cost to states of implementing the requirement. Specific concerns
raised and comments made by CMS, and our evaluation, follow.
Regarding the sufficiency of underlying data for certain findings, CMS
commented that our survey asked states about the effects of the
requirement on enrollment, although states did not provide data to
validate their responses. In addition, CMS expressed concerns that the
draft report appeared to draw broad conclusions about the effect of the
requirement from data provided by one state. The purpose of our work
was to report on the initial effects of the requirement. Absent
national CMS data on the effects and because state Medicaid offices
were largely responsible for implementing the requirement, we
determined they were the best source for this information. Though not
all states could quantify the effect of the requirement on enrollment,
22 states reported that the requirement resulted in decreases in
enrollment, 12 reported that the requirement had no effect on
enrollment, and 10 reported not knowing the effect of the requirement
on enrollment. We disagree with CMS's assertion that the draft report
drew broad conclusions about the effect of the requirement on
enrollment from one state's data. The report clearly indicates that
these data are from a single state and further notes that the extent of
the decline in Medicaid enrollment due to the requirement in some
individual states and nationally is unknown.
CMS raised concerns about one survey question that asked states that
reported enrollment declines due to the requirement the reasons for
those declines and also about the level of information provided
regarding the degree to which the requirement deterred nonqualified
aliens from applying for Medicaid. With regard to the first concern, in
responding to our survey, states could check an option that said
enrollment declines were caused by the delays in or losses of coverage
for individuals who appeared eligible. CMS objected to the use of
"appeared eligible," noting that the term is vague and subjective and
that it tends to lead the respondent to certain conclusions. However,
as we explain in the report, asking states to assess the citizenship
status of individuals is consistent with most states' experience in
making such determinations under the self-attestation policies that
were in effect prior to the DRA provision. With regard to the second
concern, we agree with CMS that our report provides limited information
about the extent to which the requirement is deterring nonqualified
aliens from applying for Medicaid. However, the report does discuss
whether CMS had evidence that such individuals were falsely declaring
citizenship when applying for Medicaid. Specifically, our report notes
that CMS in its comments to the 2005 OIG report on state self-
attestation policies acknowledged that the OIG did not find problems
regarding false allegations of citizenship, and CMS was not aware of
any such problems.
CMS commented that the draft report overstated the effect of the
requirement on enrollment because the majority of states reporting
enrollment declines attributed the declines primarily to delays in
receiving coverage rather than denials of coverage. Our report notes
the implications for individuals of such delays in coverage. The report
points out, for example, that a pregnant woman who is a citizen may be
forced to forgo needed prenatal care while her coverage is delayed by
efforts to meet the requirement. CMS also noted that its goal in
implementing the requirement was to minimize the incidence of delays in
or denials of eligibility due to the requirement.
In response to our findings that two aspects of the requirement
specified under regulations issued by CMS--namely that documents be
originals and that the list of acceptable documents is complex and does
not allow for exceptions--presented challenges to states and
individuals, CMS commented that the agency has attempted to provide as
much flexibility as possible and that other federal agencies require
original documentation. Nonetheless, our survey results clearly
indicated that these two aspects of the requirement are viewed by most
states as posing barriers to access. In particular, 42 of 44 states
reported that having to provide original documentation posed a barrier
to eligible citizens' meeting the requirement, and 34 states reported
that an individual's inability to provide documents other than those
defined under federal regulations by CMS created a barrier to
compliance. Further, while the report explains that CMS modeled its
regulations after SSA's policy for documenting citizenship when
individuals apply for a Social Security number, the report also notes
that, unlike CMS, SSA provides for flexibility in special cases.
CMS also commented on our finding that CMS's estimates of potential
savings from the requirement in fiscal year 2008 did not account for
administrative costs. Specifically, CMS agreed that its estimate did
not account for administrative costs incurred by states to implement
the requirement, but stated that any such costs would decrease after
the first year of implementation. Our report describes that some states
reported not having budgeted funds for the requirement in future years
and explains that one reason for this may be that the burden of the
requirement may decrease after the first year of implementation.
However, the ongoing costs of assisting applicants in complying with
the requirement may continue to be significant for some states,
especially those states that had to substantially modify their
enrollment procedures. For example, as noted in the report, due to the
requirement, one state faced an additional 40,000 hours of staff time
needed per month to process applications.
CMS commented that it was not surprised that states reported facing
challenges, given that the report's findings were based on states'
experiences after less than 1 year of implementing the requirement.
While agreeing that the requirement posed challenges for individuals
and states, CMS asserted that these initial challenges have diminished
and will continue to do so. Based on our survey responses, states
largely do not share CMS's optimism in this regard. In addition to
describing the initial effects of the requirement, which in states'
perspectives have included enrollment declines and increased
administrative burdens, our report includes additional indicators that
the effects states experienced in the first year will continue at least
to some extent in the future. For example, 17 of the 22 states that
reported a decline in enrollment due to the requirement reported that
they expected the downward trend in enrollment to continue, with some
expecting the decline to continue indefinitely. In addition, 15 states
reported already having budgeted funds for the requirement in state
fiscal year 2008.
CMS also emphasized actions it has taken to implement the requirement,
such as issuing a letter to state Medicaid directors, publishing an
interim final rule, and working on a final rule to be issued shortly.
Our report describes the steps taken by CMS to implement the
requirement. With regard to CMS's work on a final rule, we modified our
report to indicate CMS's plans to issue such a rule shortly.
As arranged with your offices, unless you publicly announce the
contents of this report earlier, we plan no further distribution of
this report until 30 days after its issue date. At that time, we will
send copies of this report to the Secretary of HHS, the Administrator
of the Centers for Medicare & Medicaid Services, and other interested
parties. We will also make copies available to others on request. In
addition, the report will be available at no charge on the GAO Web site
at http://www.gao.gov.
If you or your staffs have any questions about this report, please
contact me at (202) 512-7114 or cosgrovej@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major contributions
to this report are listed in appendix III.
Signed by:
James C. Cosgrove:
Director, Health Care:
[End of section]
Appendix I: List of Acceptable Documents for Proving Citizenship and
Identity, as Defined under Federal Regulations:
Federal regulations published by the Centers for Medicare & Medicaid
Services (CMS) identify primary, or tier 1, documents that are
considered sufficient to establish citizenship. Under the regulations,
if individuals do not have primary evidence, they are expected to
produce secondary, or tier 2, evidence of citizenship as well as
evidence of identity. If neither primary nor secondary evidence of
citizenship is available, individuals may provide third tier evidence
of citizenship with accompanying evidence of identity. If primary
evidence of citizenship is unavailable, secondary and third tier
evidence do not exist or cannot be obtained in a reasonable time
period, and the individual was born in the United States, then the
individual may provide fourth tier evidence of citizenship, along with
evidence of identity. See table 4 for a list of acceptable documents to
prove citizenship and table 5 for acceptable identity documents.
Table 4: List of Acceptable Documents for Proving Citizenship, as
Defined under Federal Regulations:
Level of documentation: Tier 1 (primary);
Acceptable documents: U.S. passport[A];
Restrictions: [Empty].
Level of documentation: Tier 1 (primary);
Acceptable documents: Certificate of naturalization[A];
Restrictions: [Empty].
Level of documentation: Tier 1 (primary);
Acceptable documents: Certificate of U.S. citizenship[A];
Restrictions: [Empty].
Level of documentation: Tier 1 (primary);
Acceptable documents: State- issued driver's license[A];
Restrictions: Limited to states that require proof of citizenship or
that verified the individual's Social Security number as a condition of
issuance.
Level of documentation: Tier 2 (secondary);
Acceptable documents: U.S. public birth certificate[B];
Restrictions: Certificate must have been issued before the individual
was 5 years of age.
Level of documentation: Tier 2 (secondary);
Acceptable documents: Certification of report of birth[B];
Restrictions: [Empty].
Level of documentation: Tier 2 (secondary);
Acceptable documents: Report of birth abroad of a U.S. citizen[B];
Restrictions: [Empty].
Level of documentation: Tier 2 (secondary);
Acceptable documents: Certification of birth issued by the Department
of State[B];
Restrictions: [Empty].
Level of documentation: Tier 2 (secondary);
Acceptable documents: U.S. citizen identification card issued by the
Immigration and Naturalization Service[B];
Restrictions: [Empty].
Level of documentation: Tier 2 (secondary);
Acceptable documents: Northern Mariana identification card;
Restrictions: [Empty].
Level of documentation: Tier 2 (secondary);
Acceptable documents: American Indian card;
Restrictions: Limited to cards issued by the Department of Homeland
Security to Texas Band of Kickapoos.
Level of documentation: Tier 2 (secondary);
Acceptable documents: Final adoption decree showing child's name and
U.S. place of birth;
Restrictions: [Empty].
Level of documentation: Tier 2 (secondary);
Acceptable documents: Evidence of U.S. civil service employment;
Restrictions: Limited to individuals employed before June 1, 1976.
Level of documentation: Tier 2 (secondary);
Acceptable documents: U.S. military record showing a U.S. place of
birth;
Restrictions: [Empty].
Level of documentation: Tier 3 (third level);
Acceptable documents: Hospital record indicating a U.S. place of birth;
Restrictions: Record must be on hospital letterhead and created at
least 5 years before initial application for Medicaid, or, for children
under 16, near the time of birth or 5 years before application for
Medicaid.
Level of documentation: Tier 3 (third level);
Acceptable documents: Life, health, or other insurance record
indicating U.S. place of birth;
Restrictions: Record must be created at least 5 years before initial
application for Medicaid.
Level of documentation: Tier 4 (fourth level);
Acceptable documents: Federal or state census record showing U.S.
citizenship or a U.S. place of birth;
Restrictions: Record must also show applicant's age.
Level of documentation: Tier 4 (fourth level);
Acceptable documents: Seneca Indian tribal census record;
Restrictions: Record must show a U.S. place of birth and have been
created at least 5 years before application for Medicaid.
Level of documentation: Tier 4 (fourth level);
Acceptable documents: Bureau of Indian Affairs tribal census records of
the Navajo Indians;
Restrictions: Record must show a U.S. place of birth and have been
created at least 5 years before application for Medicaid.
Level of documentation: Tier 4 (fourth level);
Acceptable documents: U.S. state vital statistics official notice of
birth registration;
Restrictions: Notice must show a U.S. place of birth and have been
created at least 5 years before application for Medicaid.
Level of documentation: Tier 4 (fourth level);
Acceptable documents: U.S. birth record amended more than 5 years after
individual's birth;
Restrictions: Record must show a U.S. place of birth and have been
created at least 5 years before application for Medicaid.
Level of documentation: Tier 4 (fourth level);
Acceptable documents: Signed statement from physician or midwife
present at birth;
Restrictions: Statement must show a U.S. place of birth and have been
created at least 5 years before application for Medicaid.
Level of documentation: Tier 4 (fourth level);
Acceptable documents: Medical record;
Restrictions: Record must show a U.S. place of birth and have been
created at least 5 years before initial application for Medicaid or,
for children under 16, near the time of birth or 5 years before
application for Medicaid.
Level of documentation: Tier 4 (fourth level);
Acceptable documents: Institutional admission papers from nursing home
or other institution;
Restrictions: Papers must show a U.S. place of birth.
Level of documentation: Tier 4 (fourth level);
Acceptable documents: Written affidavit;
Restrictions: Affidavits may be used only in rare circumstances and
must comply with several additional requirements.
Source: GAO analysis of the Deficit Reduction Act of 2005 (DRA) and
regulations published by CMS.
[A] Document identified in the DRA as an acceptable document for
proving citizenship.
[B] Document identified in the DRA as an acceptable document for
proving citizenship when accompanied by documentation of identity.
[End of table]
Table 5: Acceptable Documents for Proving Identity, as Defined under
Federal Regulations:
Level of documentation: Tier 1; Acceptable identity documents: Not
applicable.
Level of documentation: Tiers 2, 3, and 4;
Acceptable identity documents:
* Driver's license with photograph or other identifying information[A];
* School identification card with photograph[A];
* U.S. military card or draft record[A];
* Identification card issued by federal, state, or local government
with photograph or other identifying information[A];
* Military dependent's identification card[A];
* Native American Tribal document[A];
* U.S. Coast Guard Merchant Mariner card[A];
* Certificate of Degree of Indian Blood or other tribal document with
photograph or other personal identifying information;
* Cross match with other government agency if the agency establishes
and certifies true identity of individuals;
In addition, for children under 16:
* School records;
* Written affidavit if no other identity documents on the list are
available.
Source: GAO analysis of the DRA and regulations published by CMS.
[A] Document identified in the DRA as an acceptable document for
proving identity.
[End of table]
[End of section]
Appendix II: Comments from the Centers for Medicare & Medicaid
Services:
Department Of Health & Human Services:
Centers for Medicare & Medicaid Services:
Administrator:
Washington, DC 20201:
Jun 14 2007:
Mr. James Cosgrove:
Director, Health Care:
United States Government Accountability Office:
Washington, DC 20548:
Dear Mr. Cosgrove:
Thank you for submitting the Draft Report: States Report Citizenship
Documentation Resulted in Enrollment Declines for Eligible Citizens and
Posed Administrative Burdens. We appreciate the opportunity to comment,
and have several concerns we would like to address. The Centers for
Medicare & Medicaid Services (CMS) is concerned that the title of this
report is misleading, given the results of the survey and the lack of
supporting data. Although CMS does not disagree generally with the
approach of the report, we believe that GAO reached conclusions largely
based on State responses that are not substantiated by State enrollment
data.
We understand GAO undertook this survey to analyze the impact of the
new Deficit Reduction Act of 2005 (DRA) provision requiring States to
secure from applicants and recipients for Medicaid satisfactory
documentary evidence of citizenship. The provision requires that as of
July 1, 2006 citizens applying for Medicaid, or renewing their
eligibility, document their citizenship. United States citizenship or
legal immigration status has always been a requirement for Medicaid
eligibility, but prior to the DRA, States could accept a citizen
applicant's statement of citizenship as sufficient. The new law is
designed to ensure that Medicaid beneficiaries who are citizens have
documented such status without imposing undue burdens on them or the
States. This provision does not apply to applicants and recipients who
are in a legal immigration status. Such individuals continue to provide
documentation of their immigration status as previously required.
The GAO sought to determine whether States were experiencing declines
in Medicaid enrollment because of the citizenship documentation
requirements. Based on a survey devised by the GAO, the GAO found that
of the 44 States that provided complete responses to the GAO survey, 22
reported some declines in Medicaid enrollment, which may be
attributable at least in part to the citizenship documentation
requirement. Twelve States reported no decline in enrollment and 10
States did not know the effect of the requirement on enrollment. The
GAO refused to provide CMS the names of the 7 States that did not
complete the survey or fully implement the program. The GAO also did
not provide us the individual responses from the State survey. This
information would be helpful in identifying problems related to
implementation and to showing best practices among the States.
GAO asks the States to establish causality between the implementation
of the documentation requirement and enrollment declines, yet States do
not identify data sources that validate the relationship between the
implementation of the documentation requirement and enrollment levels.
In addition, we believe the report vastly overstates the conclusions
that may be drawn from the information presented within. These
conclusions are largely based on anecdotal statements or vague feelings
by some States that all declines in enrollment must be based on the new
requirements. In fact, enrollment generally ebbs and flows across
States such that at any given time one would expect declines in some
States, increases in other States, and unchanging enrollment levels in
others.
The validity of the report's conclusions is problematic. Broad
conclusions on impact appear to be drawn from data provided by one
State and generalizing this to other States seems questionable. We also
find that the numbers presented are not put into context so that the
reader may understand the relative number of impacted applicants and
recipients compared to those who do not experience difficulty in
meeting the requirement. In addition, we do not believe the report
gives sufficient attention to the effort by CMS to minimize the impact
of this requirement on States.
We agree that some States did report challenges. However, this result
was not universal. Half of the States responding did not report
declines specific to this requirement. And, even though 22 States
reported declines in Medicaid enrollment, the majority of those States
reported that this decline was primarily caused by applicants
experiencing some delay in receiving coverage, rather than a denial in
coverage. Moreover, even when reporting this delay, States did not have
the factual information to substantiate that the citizenship
requirement was in fact the basis for the delay in enrollment.
We appreciate the effort GAO undertook in doing this report and
understand the difficulty of drawing clear conclusions due to the fact
that States have relatively little specific data on the reasons for the
decline in enrollment. While it is still useful to have the benefit of
the information States provided about their implementation experiences,
the limitations of such information should be recognized. Furthermore,
the survey instrument itself has several weaknesses. Question 7 uses
the term "appeared eligible." This is a vague and subjective concept
which tends to lead the respondent to certain conclusions rather than
being precise, because there are many reasons that someone who may
"appear" at first meeting to be eligible is ultimately found
ineligible. Questions 16 and 17 ask what application method was/is most
commonly used, such as mail-in, in person, etc. It is the experience of
CMS that States use multiple methods of taking applications that in
many cases are unique to specific eligibility groups. Without this
information, it is difficult to make worthwhile conclusions. Question
34, did not ask for the number or percentage of applicants experiencing
the barriers listed.
The report describes State implementation experiences after less than
one year implementing a new documentation requirement. States for 10-15
years prior to implementation had been generally relying on self
declaration without verification except in unusual circumstances. The
generalized practice of minimizing documentation over these years
followed by an abrupt shift to more documentation unsurprisingly has
caused some challenges for States in operationalizing the new
requirements in a very short timeframe. With little time to prepare for
a major shift in outlook by States, eligibility workers, and the client
population, the rather small declines generally being reported are a
testament to the success of States' implementation. The report also
sheds very little light, beyond the presupposition that citizens are
the ones unable to document their citizenship, about whether the
provision is deterring nonqualified aliens from applying for regular
Medicaid.
Among the major complaints of States, as reported by the GAO, is the
requirement that originals of documents be submitted, especially when
the application process is a mail-in process. Consequently, the
requirement for originals of documents presents some administrative
challenges. In this context, we note that the Social Security
Administration (SSA) requires originals prior to establishing
eligibility. Likewise, the Department of State requires original
documents or certified copies prior to issuing a passport. We also,
considered the option of permitting copies, but concluded that program
integrity would best be served by requiring originals or certified
copies.
The GAO indicates in the report that CMS may have overestimated
potential savings in the interim final rule with comment period. CMS
notes that the regulatory impact statement was calculated to estimate
changes in Medicaid expenditures for claims. It did not account for the
administrative impact on States. With respect to administrative costs,
CMS provides federal match for administrative expenditures. We would
expect States to experience higher administrative costs during the
first year of implementation as they adjust to the new requirements. We
also expect these costs to decrease in later years as current
recipients meet the requirements and only new applicants are required
to submit documentation. Furthermore, the exemption of several groups
of individuals authorized under both the DRA and the Tax Relief and
Health Care Act of 2006 (TRHCA) will significantly reduce the number of
individuals from whom States must collect documentation. Administrative
costs may be further reduced by the States' ability to cross-verify
with the Systematic Alien Verification for Entitlements (SAVE)
database, to which they already have access. Data matches with the
State's vital statistics agency could further reduce administrative
costs.
The CMS has undertaken a number of positive steps to implement the
citizenship documentation requirements. Among these are: (a) issuing a
State Medicaid Directors' letter and interim final rule soon after
publication of the DRA which expanded upon the documents that could be
used in proving identity and citizenship; (b) providing extensive
leadership and training to the States so that they could implement the
requirement; (c) working closely with the SSA and other agencies to
ensure that the requirements reflected standards already used by other
Federal agencies that verify citizenship; (d) working on the issuance
of a final rule that should be issued shortly and that will respond to
comments; and (e) encouraging States to use electronic matching
whenever possible. We believe that these activities play a vital role
in assisting the States in understanding the new documentation
requirements under the law. Conveying all of this information to States
and beneficiaries is a massive undertaking and we anticipate that with
time the documentation requirements will be recognized and understood
as another aspect of the Medicaid eligibility process.
CMS has attempted to provide as much flexibility as possible and
consistent with the provisions of the DRA in the documents applicants
and recipients could use to document citizenship. Further, any
requirement to provide documentation by its nature adds to the
responsibility of the individual and the workload of the State. We also
believe any initial impact has diminished as States and applicants
become familiar with the documentation requirement. We expect to see a
reduction in delays or denials for lack of documentation once the
startup issues are resolved. Moreover, we are pleased with the more
expansive list of documents that has been published to assist States in
fulfilling the statutory documentation requirement. We believe that
through these documents and/or data matches, States have sufficient
tools to assure that any citizen can provide the necessary documents to
meet the documentation requirement, and the State will not be found at
risk for providing Medicaid to undocumented citizens.
Our goal from the beginning has been to minimize the incidence of
delays in or denials of eligibility because of this provision. Thus, we
have encouraged States to conduct data matches with vital statistics
agencies and other governmental agencies for identity. The information
we have received from States indicate that producing identity documents
for young children has been the largest problem States have
encountered, and we will clarify this issue in the final regulation.
We conclude also by noting that GAO made no recommendations to CMS in
the report. Enclosed are additional technical comments. Again, thank
you for the opportunity to comment. If you have any questions please
feel free to contact me.
Sincerely,
Signed by:
Leslie V. Norwalk, Esq.
Acting Administrator:
Enclosure:
[End of section]
Appendix III: GAO Contact and Staff Acknowledgments:
GAO Contact:
James C. Cosgrove, (202) 512-7114 or cosgrovej@gao.gov:
Acknowledgments:
Kathryn Allen, Director, led the engagement through its initial phases.
In addition, Susan Anthony, Assistant Director; Susan Barnidge; Laura
Brogan; Elizabeth T. Morrison; and Hemi Tewarson made key contributions
to this report.
FOOTNOTES
[1] DRA, Pub. L. No. 109-171, 120 Stat. 4 (2006).
[2] For the purposes of qualifying for Medicaid as a U.S. citizen, the
United States is defined as the 50 states, the District of Columbia,
Puerto Rico, Guam, U.S. Virgin Islands, and the Northern Mariana
Islands. Nationals from American Samoa or Swain's Island are also
regarded as U.S. citizens for purposes of Medicaid. In this report, we
combine references to the requirements to document U.S. citizenship or
nationality under the broader rubric of documenting citizenship.
[3] DRA, Pub. L. No. 109-171, § 6036, 120 Stat. 80-81 (to be codified
at 42 U.S.C. §1396b). The DRA exempted certain groups of individuals,
including individuals entitled to or enrolled in Medicare and certain
Supplemental Security Income beneficiaries, from documenting
citizenship.
[4] In a July 2005 report regarding states' oversight of the self-
declaration of U.S. citizenship, the Office of Inspector General (OIG)
of the Department of Health and Human Services (HHS) identified 47
states that allowed self-attestation of citizenship for U.S. citizens
and nationals. However, the HHS OIG reported that nearly all of these
states had a written or informal "prudent person policy," which
required individuals to submit documentary evidence when eligibility
staff questioned the validity of their attestations. The remaining 4
states independently required U.S. citizens and nationals to provide
documentary evidence of their citizenship status in order to qualify
for their state Medicaid programs. HHS, OIG, Self-Declaration of U.S.
Citizenship for Medicaid (July 2005).
[5] CMS is the agency within HHS responsible for administering the
Medicaid program, including oversight of the citizenship documentation
requirement.
[6] Medicaid Program; Citizenship Documentation Requirements, 71 Fed.
Reg. 39,214 (July 12, 2006). For the purposes of this report, we refer
to the requirement to document citizenship in the DRA and the related
requirements identified in the implementing federal regulations as "the
requirement."
[7] Tax Relief and Health Care Act of 2006, Pub. L. No. 109-432, title
IV, §405(c), 120 stat. 2922, 2998-2999 (2006) (to be codified at 42
U.S.C. §1396b(x)(2)).
[8] Specifically, in response to the July 2005 report by the OIG of HHS
regarding states' oversight of the self-declaration of U.S.
citizenship, CMS acknowledged that the OIG did not find problems
regarding false allegations of citizenship and further noted that CMS
was not aware of any such problems.
[9] Throughout this report, the term "state" refers to the 50 states
and the District of Columbia.
[10] Three of the 4 states reported taking steps to implement the
requirement, such as conducting data matches for existing
beneficiaries, but, for example, were awaiting issuance of state
regulations before fully implementing. The remaining state reported
that it implemented the requirement in April 2007. As of May 2007, CMS
was aware that not all states had fully implemented the requirement.
[11] These 44 states accounted for 71 percent of national Medicaid
enrollment in fiscal year 2004, the most recent year that CMS data are
available. The 2 states not responding to the survey represented 5
percent of Medicaid enrollment in fiscal year 2004, and the 5 states
excluded from our analysis constituted the remaining 23 percent.
[12] In the survey, we asked states whether they thought enrollment
declines were due, in part, to individuals who appeared to be eligible
citizens experiencing delays or losses in Medicaid coverage. We
believed that states' assessments of individuals' citizenship were
appropriate given their reliance on prudent person policies to make
such determinations under their prior self-attestation policies.
[13] States define their fiscal years differently. For example, some
states' fiscal years are the same as the federal fiscal year (October 1
through September 30), while in other states, the fiscal year runs from
July 1 to June 30.
[14] Under a statutory formula, the federal government may pay from 50
to 83 percent of a state's Medicaid expenditures, known as the Federal
Medical Assistance Percentage (FMAP). States with lower per capita
incomes receive higher FMAP matching rates. The FMAP for administrative
costs is the same for all states and is generally 50 percent for
administrative costs. 42 U.S.C. §§ 1396b(a), 1396d(b).
[15] See 42 U.S.C. § 1396a(a)(10).
[16] Immigration Reform and Control Act of 1986, Pub. L. No. 99-603, §
121, 100 Stat. 3359, 3384-3391 (1986) (codified, as amended, at 42
U.S.C. § 1320b-7). Under this law, individuals who declared themselves
aliens in satisfactory immigration status were required to present
specific documentary evidence of their status, while those who declared
themselves citizens were not. Individuals in satisfactory immigration
status include aliens who are lawful permanent residents, refugees, and
other aliens under special circumstances.
[17] Federal Medicaid regulations require states to redetermine the
eligibility of a Medicaid beneficiary at least once every 12 months or
more frequently if the state receives information that may affect the
eligibility of the Medicaid beneficiary. 42 C.F.R. 435.916.
[18] For example, the DRA provided states with the ability, under a
State Plan Amendment, to restructure Medicaid benefit packages based on
newly defined criteria and to impose varying levels of cost-sharing for
certain Medicaid populations. See DRA, Pub. L. No. 109-171, §§ 6041-
6044, 120 Stat. 81-92 (2006) (to be codified at 42 U.S.C. §§ 1396o-1,
1396u-7).
[19] DRA, Pub. L. No. 109-171, § 6036, 120 Stat. 80-81 (2006) (to be
codified at 42 U.S.C. § 1396b). The DRA, however, did not impose any
additional requirements for Medicaid applicants and beneficiaries who
declare themselves aliens in satisfactory immigration status.
[20] "Satisfactory documentary evidence" is defined as a list of
specific documents, such as a U.S. passport, and includes those
documents that the Secretary of HHS determines, under federal
regulations, to provide proof of citizenship and a reliable means of
identification.
[21] The DRA permits such a designation only when the Secretary of HHS
finds that satisfactory documentary evidence of citizenship had been
previously presented.
[22] See Tax Relief and Health Care Act of 2006, Pub. L. No. 109-432,
title IV, § 405(c), 120 Stat. 2922, 2998-2999 (2006) (to be codified at
42 U.S.C. § 1396b(x)(2)).
[23] As of June 2007, CMS indicated that a final rule is forthcoming.
[24] In order to meet its obligations under the Paperwork Reduction Act
of 1995, CMS solicited comments on these estimates.
[25] CMS did not perform a detailed analysis of the costs and benefits
prior to issuing this rule, as would otherwise be required under the
Unfunded Mandates Reform Act of 1995, because it determined that the
cost would be less than $100 million (or approximately $120 million in
2006 dollars) for any 1 year.
[26] Of the 44 states, all reported implementing the requirement as of
January 2007: 33 implemented the requirement in July 2006, the month
that the requirement became effective, 8 did so within the 2 months
following, and 3 did so within 6 months of the July 1, 2006, effective
date.
[27] The last state did not answer the survey question about the
reasons that the requirement led to a decline in enrollment.
[28] This state's total Medicaid enrollment was about 970,000 in fiscal
year 2004, the most recent year of enrollment data available.
[29] The remaining 2 states did not indicate how long the trend would
continue.
[30] Of these 5 states, 2 noted that they had already documented
citizenship for current Medicaid beneficiaries; 1 reported that it
accepts photocopies of acceptable documentation; and the remaining 2
expected people eventually to provide the necessary documents and
qualify for Medicaid.
[31] The sixth state responded that it did not know the effects of the
requirement on enrollment.
[32] Of the 5 remaining states, 3 reported they did not know the effect
of the requirement on enrollment, and 2 reported the requirement had no
effect on enrollment.
[33] However, states did not define what is considered a good faith
effort.
[34] If the applicant is determined eligible, she generally would
qualify for Medicaid 3 months prior to the date of her application if
she met eligibility requirements during that period. Accordingly, she
can be reimbursed for the cost of an ultrasound provided during the
retroactive coverage period, but she may first be required to pay the
full out-of-pocket cost at the time of service, which many Medicaid-
eligible individuals may find difficult to afford.
[35] In 2005, the most recent year of Medicaid expenditure data
available from CMS, the 10 states' Medicaid administrative expenditures
ranged from approximately $22 million to over $320 million. The amount
of funds that states reported were appropriated to implement the
requirement represented from 1 percent to 12 percent of each state's
respective 2005 Medicaid administrative expenditures.
[36] To the extent that states increase Medicaid administrative
spending to implement the requirement, the federal government will
share in the costs.
[37] The remaining states (9 of 35) did not specify the amount of
additional state processing time resulting from the requirement.
[38] After implementing the requirement, some states also observed
increases in the number of pending applications per month and a
decrease in the number of redeterminations completed per month,
indicating larger caseloads for some eligibility workers. For example,
20 of the 26 states with data available on applications reported an
increase in the number of pending applications per month after
implementing the requirement, with just over half of states observing
increases of at least 30 percent. In 3 states, this increase
represented an additional 10,000 pending applications per month as
compared to the average number of pending applications per month prior
to implementing the requirement.
[39] For example, according to CMS, the National Association for Public
Health Statistics and Information Systems, an association of vital
statistics agencies, is engaged in creating and making available a
database and linking system to permit interstate electronic
verification of vital statistics information.
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