A National Council Issue Brief

Section 6036 of the Deficit Reduction Act (DRA), which became effective on July 1, 2006, requires proof of citizenship before new applicants can receive Medicaid. Prior to the DRA, infants born in the US to Medicaid-eligible mothers were deemed eligible for Medicaid and automatically enrolled. CMS issued interim final rules interpreting the DRA to require citizenship documentation from infants born in US hospitals. A recent study shows that CMS guidelines and some state policies may be having a negative affect on Medicaid coverage for newborns.

On January 9, the Kaiser Family Foundation released their findings from a 50-state survey, Trends in Access to Medicaid and SCHIP Coverage. The overall findings were positive—17 states increased access to health coverage, and for the first time in four years, no state cut income eligibility in Medicaid and SCHIP. (Kaiser Daily Health Policy Report, January 10, 2007) However, since the DRA's citizenship provisions took effect on July 1, 2007, some states are reporting declining Medicaid enrollment, a phenomenon states are linking directly to the new citizenship requirements. In some cases, states are reporting delays in enrollment due to backlogs caused by the new paperwork; in others, the parents believe their children are no longer eligible and don't apply or they cannot produce the required documents. These changes have come at a time when most states had reduced obstacles to Medicaid enrollment.

According to the American Academy of Pediatrics, Medicaid officials in Georgia, Kentucky, Tennessee and Virginia are requiring mothers to apply for Medicaid coverage for their newborns. In the past, these states deemed these children automatically eligible for emergency Medicaid. (CQ Healthbeat News, October 17, 2006) According to the Kaiser report, states reporting enrollment declines include Iowa, Louisiana, New Hampshire, Virginia and Wisconsin. (Kaiser Family Foundation, Resuming the Path to Health Coverage for Children and Parents: A 50 State Update, January 2007 — www.kff.org/medicaid/upload/7608.pdf)

Officials in states with declining enrollments say the law is having unintended consequences—rather than preventing undocumented immigrants from obtaining Medicaid, the citizenship requirements are preventing children from U.S. citizens and documented immigrants from receiving the Medicaid coverage to which they are entitled. In Louisiana, for example, the procedural closure rate at renewal has tripled, from 5 percent to 16-17 percent. Officials there say the increase is not attributable to population loss after hurricane Katrina. Similarly, Anita Smith of the Iowa Department of Human Services reported, "There is no evidence that the decline is due to undocumented aliens leaving the program. Rather, we believe that these new requirements are keeping otherwise eligible citizens from receiving Medicaid because they cannot provide the documents required to prove their citizenship or identity." As Cindi Jones, chief deputy director of the Virginia Department of Medical Assistance Services, observed, "If there are hurdles in their way, many families give up."

Early Medicaid coverage is particularly important for children who have developmental delays or other special needs. In a letter to CMS requesting clarification of the new law, several national organizations noted "reports...that some newborns with special needs are remaining in the hospital because their lack of coverage prevents the hospital from arranging home care and other necessary follow-up services." (Letter to CMS from the American Academy of Family Physicians et. al., October 12, 2006)

The DRA requires proof of both citizenship and identity. Parents may be unable to obtain birth certificates for a variety of reasons—e.g., inability to pay fees, difficulty taking time off of work to wait in line, lack of transportation and child care. These problems are magnified when the family is not living in the child's state of birth. Some states have lessened the burden on parents by confirming birth records through data matches with Vital Records. Not all states have such technology available to them, and there is no system for one state to conduct a data match for a child born in another state. Some states are including in Medicaid application materials an affidavit form parents can use to attest to the identity of children under 16 years of age.

New Hampshire's experience demonstrates that the obstacle is not citizenship but documentation. New Hampshire is one of only four states that had a citizenship documentation requirement prior to the DRA's enactment. Under the new federal requirements, case closure due to lack of proper documentation has doubled in the state. Unlike other states, New Hampshire does not allow parents to submit affidavits attesting to the identity of children under 16 years of age.

The 109th Congress did not include citizenship documentation in the DRA technical changes package that was passed in December. For more information on these technical corrections, see the December 14th issue of the Public Policy Update - www.nccbh.org/POLICY/public_policy_updates/ppu_12-14-06.htm. Legislation has been introduced in the House (H.R. 210: the Medicaid Newborn Coverage Act of 2007 - http://thomas.loc.gov/cgi-bin/bdquery/z?d110:h210:) that would waive the requirement for proof of citizenship during the first year of life for children born in the U.S. to Medicaid-eligible mothers. Thus far, nothing similar has been introduced in the Senate.

Rather than wait for a Congressional or administrative solution, states would be well served by using every means at their disposal to ease the impact of the citizenship documentation requirement on low-income families. Although states may not be able to access vital records of other states, they can control the development and use of technology in their own jurisdictions. Using a vital records database match removes many barriers for parents. States that lack such technology can also reduce or waive document fees for Medicaid-eligible parents, provide multiple copies of the original birth certificate upon issuance, and contract with advocacy and provider organizations to assist parents in obtaining the proper documents. Another low-technology practice states could adopt would be to include in their Medicaid application materials an affidavit form parents can use to attest to the identity of children under 16 years of age. As most states realized before the DRA's passage, removing obstacles for parents is critical to ensuring that more eligible children benefit from Medicaid services.

For more information, please contact Tammy Seltzer at TammyS@nccbh.org.