Medicaid Citizenship Documentation
Medicaid Citizenship Documentation
April Grady
Analyst in Health Care Financing
Domestic Social Policy Division
Summary
Due to recent changes in federal law, individuals who declare that they are citizens
for Medicaid eligibility purposes must present documentation that proves citizenship
and documents personal identity. This report discusses issues related to Medicaid
citizenship documentation that have received considerable media and interest group
attention, as well as proposed legislation (including H.R. 210, H.R. 1238, H.R. 1328,
S. 1200, S. 2532, S. 751, S. 909, H.R. 1535, S. 895, H.R. 1878, H.R. 2055, S. 1224, S.
3888, and H.R. 4144 in the 110th Congress) that would affect the requirement. It will
be updated to reflect significant legislative or other activity.
Overview of Citizenship Requirements for Medicaid
To be eligible for the full range of benefits offered under Medicaid, an individual
must be a citizen or national1 of the United States or a qualified alien.2 Nonqualified
aliens can only receive limited emergency Medicaid benefits (all discussion in this report
will refer to full Medicaid, unless otherwise noted).3 Regardless of citizenship status,
individuals must meet all other eligibility requirements to qualify for the program.
Since the Immigration Reform and Control Act of 1986 (IRCA, P.L. 99-603), states
have been required to obtain a written declaration, under penalty of perjury, stating
whether individuals applying for full Medicaid benefits are U.S. citizens or nationals.
Individuals who declare that they are not citizens have also been required since IRCA to
1 Throughout this report, references to citizens also include nationals.
2 The term qualified alien was created by P.L. 104-193. Examples include legal permanent
residents (LPRs), refugees, and asylees. LPRs entering after August 22, 1996, are barred from
receiving full Medicaid benefits for five years, after which coverage becomes a state option.
3 Examples include those who are unauthorized or illegally present and nonimmigrants who are
admitted for a temporary purpose. See CRS Report RL31630, Federal Funding for Unauthorized
Aliens’ Emergency Medical Expenses, by Alison Siskin, and CRS Report RL33809, Noncitizen
Eligibility for Federal Public Assistance: Policy Overview and Trends, by Ruth Ellen Wasem.
present supporting documentation that indicates a “satisfactory immigration status.” Due
to recent changes in federal law, individuals who declare that they are citizens also must
present documentation that proves citizenship and documents personal identity. This
Medicaid citizenship documentation requirement was included in the Deficit Reduction
Act of 2005 (DRA, P.L. 109-171) and modified by the Tax Relief and Health Care Act
of 2006 (TRHCA, P.L. 109-432). It applies to Medicaid eligibility determinations and
redeterminations made on or after July 1, 2006. The law specifies documents that are
acceptable for this purpose and exempts certain groups from the requirement, including
people who receive Medicare benefits, Social Security benefits on the basis of a disability,
Supplemental Security Income benefits, or child welfare, adoption, or foster care
assistance under Title IV-B or Title IV-E of the Social Security Act. Before DRA, states
could accept self-declaration of citizenship for Medicaid, although some chose to require
additional supporting evidence.4
The citizenship documentation requirement does not apply to the State Children’s
Health Insurance Program (SCHIP). However, some states use the same enrollment
procedures for all Medicaid and SCHIP applicants. As a result, some SCHIP enrollees
might be required to present evidence of citizenship.
Citizenship Documentation Issues
Proponents of the new citizenship documentation requirement say that it will deter
unauthorized aliens and other ineligible noncitizens from obtaining full Medicaid benefits
by falsely claiming to be citizens; that it levels the playing field by holding citizens to the
same documentation standards as noncitizens; and that the burden on individuals should
be minimal because similar documentation is required in other settings (such as obtaining
a driver’s license). Opponents say there is little evidence that noncitizen fraud has been
a problem; that many eligible individuals will experience delayed or denied enrollment
because they do not have the necessary documents on hand; and that the requirement is
burdensome for states. Since the enactment of DRA, as well as the publication of interim
and final rules,5 the requirement has received considerable media and interest group
attention. Some of the most prominent issues are discussed below.
Newborns. Under a provision of federal law that predates the citizenship
documentation requirement, a child born to a woman eligible for and receiving Medicaid
on the date of the child’s birth is automatically deemed eligible for Medicaid for one year,
so long as the child is a member of the mother’s household and the mother remains (or6
would remain if pregnant) eligible for Medicaid. At the end of the year, the child’s
eligibility must be redetermined. As a result of the new citizenship documentation
requirement, which does not provide an exception for newborns, the child’s citizenship
must be documented as part of the redetermination.
4 Department of Health and Human Services, Office of Inspector General, Self-Declaration of
U.S. Citizenship for Medicaid, OEI-02-03-00190, July 2005.
5 See 72 Federal Register 38662, July 13, 2007 and [http://www.cms.hhs.gov/Medicaid
Eligibility/05_ProofofCitizenship.asp].
6 Section 1902(e)(4) of the Social Security Act.
In the past, at least 20 states chose to deem eligibility for children — who are U.S.
citizens by virtue of their birth in the United States7 — born to noncitizen women on
emergency Medicaid, as they did for children born to women receiving full Medicaid
benefits.8 However, in the preamble to its July 2006 interim final rule on citizenship
documentation, the Centers for Medicare and Medicaid Services (CMS) stated that
children born to women on emergency Medicaid should not be deemed eligible because
the mother would not remain eligible for Medicaid if pregnant; therefore a Medicaid
application must be filed for the newborn (who is likely to qualify for coverage through
a poverty-related eligibility pathway), and the child’s U.S. citizenship must be
documented. CMS changed its position in a March 2007 press release and in its July
2007 final rule, which states that deemed eligibility applies to all qualified children born
to women receiving Medicaid, including emergency Medicaid. As with other deemed
eligible newborns, citizenship documentation is still required when the child’s eligibility
is redetermined at the end of the year.
A number of groups had expressed concern that the previous CMS interpretation of
the deemed eligibility statute could impede access to care for newborns by delaying their
Medicaid enrollment and increasing the chances that a health care provider would refuse
to see them because they lack insurance coverage. To bridge the coverage gap between
Medicaid application and approval, states can opt to use presumptive eligibility (an option
in federal statute that allows certain individuals to receive temporary coverage while their
application is processed). However, states must do so for all children under age 19,
making it potentially unattractive to those that would prefer to target a specific age group
such as newborns. Under another provision of federal law, states must provide retroactive
coverage for individuals who would have been eligible in the three months prior to their
application for Medicaid.9 This allows health care providers to be reimbursed, albeit on
a delayed schedule, for services provided before a Medicaid application is approved.
Although deemed eligibility may no longer be an issue, some still assert that a child
whose birth occurs in a U.S. hospital and is paid for by Medicaid should be entirely
exempt from the citizenship documentation requirement. For these children, the argument
is that a state’s own Medicaid records are enough to prove that they are U.S. citizens.
Reasonable Opportunity. Citizens and noncitizens appear to face disparate
treatment when it comes to the availability of Medicaid benefits before evidence of
citizenship or immigration status has been presented. As with the interim final rule, the
final rule on citizenship documentation requires states to provide citizens with a
reasonable opportunity to present evidence before taking action on their Medicaid
eligibility, but specifies that citizen applicants should not be made eligible until they have
presented the required citizenship documentation. Federal law also requires states to
provide noncitizens with a reasonable opportunity to present evidence. However, unlike
the rule on documentation for citizens, states may not delay, deny, reduce, or terminate
7 CRS Report RL33079, U.S. Citizenship of Persons Born in the United States to Alien Parents,
by Margaret Mikyung Lee.
8 National Health Law Program, State Responses to the CMS Policy Change on Medicaid
Coverage for Newborns, September 2006.
9 Section 1902(a)(34) of the Social Security Act.
Medicaid benefits for a noncitizen on the basis of immigration status until the reasonable
opportunity has been provided.10
Acceptable Documents. Some have applauded CMS for expanding on the list
of acceptable documents provided in DRA and allowing states to obtain documentation
through electronic data matching. Others have argued for an even broader list, and
expressed concern that restrictions not required by DRA have been imposed. For
example, the final rule requires all documents to be originals or copies certified by the
issuing agency. Although many states have simplified their eligibility processes by
allowing applications and renewals by mail, some argue that individuals may view a visit
to a Medicaid office as their only option when the alternatives include sending original
documents — such as passports, birth certificates, and driver’s licenses — through the
mail with no guaranteed return, or paying to obtain certified copies instead.
State Implementation. Although the citizenship documentation requirement took
effect on July 1, 2006, some states delayed implementation, citing reasons such as the
need to train eligibility staff and adequately notify beneficiaries (for example, California
implemented the requirement in June 2007). Despite the possibility that federal Medicaid
funds could be withheld from states for periods when they were not in compliance with
the law, a CMS spokeswoman has said it is unclear whether there is “zeal” to do so.11
Based on a recent survey by the Government Accountability Office (GAO), 22 of 44
states report declines in enrollment due to the new citizenship documentation
requirement.12 Based on another survey by the Kaiser Commission on Medicaid and the
Uninsured, 13 states report a significant negative impact on enrollment and another 24
states report a modest impact.13 Among seven states detailed in an earlier report from the
Center on Budget and Policy Priorities,14 only Wisconsin has a data system that can
identify denials and terminations due to a lack of citizenship documentation, and it reports
that about 19,000 people had their Medicaid eligibility denied or terminated for this
reason between July 31, 2006, and March 1, 2007.
10 Section 1137(d)(4) of the Social Security Act. It is unclear how states may be implementing
this requirement in practice. For example, Delaware indicates that it will provide a 30-day period
of eligibility when a noncitizen meets all other eligibility requirements aside from documentation.
In contrast, Hawaii indicates that it will only grant eligibility to an alien that has not submitted
documentation if the state fails to provide a reasonable opportunity or if the 10-day reasonable
opportunity period goes beyond the 45th day following the date of application. (Policies were
obtained from a database compiled by CCH, a proprietary information service.)
11 See Clea Benson, “Medi-Cal ID Rules Readied,” The Sacramento Bee, February 25, 2007.
12 GAO, States Reported That Citizenship Documentation Requirement Resulted in Enrollment
Declines for Eligible Citizens and Posed Administrative Burdens, GAO-07-889, June 2007.
13 Vernon Smith et al., As Tough Times Wane, States Act to Improve Medicaid Coverage and
Quality: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2007 and 2008,
Kaiser Commission on Medicaid and the Uninsured, October 2007.
14 Donna Cohen Ross, New Medicaid Citizenship Documentation Requirement Is Taking a Toll,
Center on Budget and Policy Priorities, revised March 13, 2007.
Even if most or all of the reported Medicaid enrollment declines are due to the
citizenship documentation requirement, a key question is whether the people who are
being denied, terminated, or deterred from applying are U.S. citizens, rather than
unauthorized aliens or other ineligible noncitizens. Of the 22 states reporting enrollment
declines to GAO, a majority (16 states) attribute them to Medicaid coverage delays or
losses for people who appear to be U.S. citizens. The extent to which the citizenship
requirement is deterring ineligible noncitizens from applying for Medicaid is unknown.15
Administrative costs are also an issue. According to both GAO and Kaiser, most
states report that they are spending more time completing applications and
redeterminations. GAO reports that 27 states appropriated or budgeted funds in state
fiscal year (SFY) 2007 or 2008 to implement the citizenship documentation requirement.16
Kaiser reports that 19 states indicated a significant increase in administrative costs, and
that another 26 states indicated a modest increase. States will receive federal
reimbursement for these costs using the 50% rate that applies to most Medicaid
administrative functions. Since existing enrollees must present documentation at their
next eligibility redetermination (a process that generally occurs at least once a year),
administrative costs should peak in the year following implementation of the requirement.
Costs in later years should be lower, reflecting the ongoing expense of documenting those
who are new to the program.
Legislative and Other Activity
In the 110th Congress,17 a number of bills that would affect the Medicaid citizenship
documentation requirement have been introduced:
!H.R. 210 would exempt all children born to women on Medicaid,
including emergency Medicaid, from the citizenship documentation
requirement during their first year of life.
!H.R. 1238 would have the effect of permanently exempting all children
born to women on Medicaid, including emergency Medicaid, from the
citizenship documentation requirement by allowing a state’s own
Medicaid records to serve as proof of citizenship in cases where a child’s
birth is paid for by the program.
!H.R. 1328, S. 1200 (as passed by the Senate in February), and S. 2532
would require additional documentation options for federally recognized
Indian tribes.
!S. 751 would require deemed eligibility and separate identification
numbers for children born to noncitizen mothers on emergency
Medicaid,18 permanently exempt all children who are deemed eligible for
15 See discussion of this issue in GAO, States Reported, pp. 27-28.
16 For 10 states reporting appropriated funds in SFY2007, the amount represented from 1% to
17 In the 109th Congress, three bills were introduced to repeal or delay implementation of the
documentation requirement (S. 2305, S. 3590, and H.R. 5023). Two others (S. 3524 and S. 4122)
would have required additional documentation options for federally recognized Indian tribes.
18 Under current law, services provided to newborns who are deemed eligible for a year of
(continued...)
an automatic year of coverage from the citizenship documentation
requirement, and allow states to provide retroactive eligibility for certain
individuals who were previously denied.
!S. 909, H.R. 1535, S. 895, H.R. 1878, H.R. 2055, S. 1224, and S. 1364
would make citizenship documentation a state option (using criteria that
are no more stringent than those used by the Social Security
Administration), require additional documentation options for federally
recognized Indian tribes, specify the reasonable opportunity period for
those who are required to present documentation, permanently exempt all
children who are deemed eligible for an automatic year of coverage from
the citizenship documentation requirement, and allow states to provide
retroactive eligibility for certain individuals who were previously denied.
!S. 1893/H.R. 976 (as passed by the Senate in August, amended and
passed by the House and Senate in September, and vetoed by President
Bush in October), H.R. 3269, and H.R. 3963 (as vetoed by President
Bush in December) would allow states to meet citizenship documentation
requirements through name and Social Security number validation, make
citizenship documentation a requirement for SCHIP, provide an
enhanced match for certain administrative costs, include the changes
described above for S. 909 (with the exception of making documentation
entirely optional), and require separate identification numbers for
children born to women on emergency Medicaid.
!H.R. 3162 (as passed by the House in August) would make Medicaid
citizenship documentation for children under age 21 a state option (using
criteria that are no more stringent than existing rules) and include the
changes described above for S. 909 (with the exception of making
documentation entirely optional). It would also allow “Express Lane”
agencies to determine eligibility without citizenship documentation and
require eligibility audits to ensure that federal funds are not spent on
individuals who are not legal residents.
!H.R. 3176, S. 2193, and H.R. 3888 would make citizenship
documentation a requirement for SCHIP and provide an enhanced match
for certain administrative costs.
!H.R. 4144 would make citizenship documentation a requirement for
SCHIP, using language that differs from the Medicaid requirement.
As described earlier, CMS clarified in its final rule that deemed eligibility applies
to all qualified children born to women receiving Medicaid, including emergency
Medicaid. However, a number of the bills cited above would go beyond the final rule by
permanently exempting all deemed eligible children from the citizenship documentation
requirement19 and removing the requirement that a newborn remain in his or her
Medicaid-eligible mother’s household in order to qualify for deemed eligibility.
18 (...continued)
coverage may be billed under their mother’s identification number.
19 The final rule states that documentation may be required again if there is a gap of more than
three years between an individual’s last period of eligibility and subsequent application for
Medicaid. This is because states are only required to retain records for three years (a longer
period is optional). If there is a new permanent exemption for deemed eligible children, states
would have to retain their records on this subset of enrollees for a much longer period of time.