Congress Revisits Medicaid ID Law

Retooling the law, which requires Medicaid patients to prove their citizenship, is one small part of federal legislation to extend the State Children’s Health Insurance Program beyond its Sept. 30 expiration date. The decade-old program provides health insurance for 6 million Americans, mostly children, whose families can’t afford private insurance but who earn too much to qualify for Medicaid.

House and Senate negotiators are hammering out the last details of an SCHIP agreement this week, despite President Bush’s threats to veto the legislation. Bush said the congressional plan would be too expensive. Congress is working on a plan to expand SCHIP to cover 10 million more people at a price of $35 billion in new spending over the next five years.

“The proposal would move millions of American children who now have private health insurance into government-run health care. Our goal should be for children who have no health insurance to be able to get private coverage, not for children who already have private health insurance to be able to get government coverage,” Bush said Thursday (Sept. 20).

The president asked Congress to temporarily extend the program beyond Sept. 30, but congressional Democrats vowed again Thursday to seek a permanent resolution. They’re trying to craft a compromise to attract enough Republicans to override Bush’s veto.

In working out an SCHIP deal, House and Senate negotiators also are seeking agreement on changes to the Medicaid documentation law, which passed last year in the Deficit Reduction Act. The law requires Americans asking for Medicaid benefits to prove they are citizens by producing certain government-produced documents, such as birth certificates or passports.

States report the new requirement has created roadblocks for many qualified applicants. Plus, state officials say, it has cost them millions of dollars to comply with and has caused backlogs and confusion among administrators and applicants.

To qualify for Medicaid, applicants were previously allowed to provide either official documents or unofficial ones, such as baptism certificates or birth announcements, to prove citizenship. In some cases, states approved enrollees after they swore under oath that they were citizens. Only U.S. citizens and certain legal immigrants, who must prove they’re authorized to be in the country, qualify for Medicaid.

At this point, Congress is weighing competing fixes to the documentation requirements.

The House voted to let states go back to the old rules, but only for kids, not adults. The Senate, on the other hand, would give states another option for verifying citizenship: checking identification electronically with the federal Social Security Administration. But the Senate’s version would also make SCHIP enrollees go through the same checks as Medicaid recipients, a step they have not had to take under the current law.

The backtracking comes because states report they’re spending more money to comply with the documentation law but have found very few illegal immigrants receiving benefits. 

For example, more than 10,000 Virginians – mostly children – lost coverage since the law took effect in July 2006. But, as far as Virginia officials can tell, only two of those dropped from the program were illegal immigrants, and both thought they were U.S. citizens.

Officials attribute at least part of the decrease to enrollees being unable to produce the necessary documents or unwilling to deal with the hassle of reapplying.

There are several reasons U.S. citizens might not have birth certificates, apart from just losing them. Many older Americans born at home or Native Americans born on Indian reservations never received a birth certificate. Plus, during the days of segregation, blacks in the South were often denied admittance to hospitals for childbirth.

While Virginia saw a sizable enrollment decline, the law has had only “negligible” effects in neighboring North Carolina, according to a spokesman there.

The changes caused considerable headaches in California, where the Legislature demanded hearings and Gov. Arnold Schwarzenegger (R) called on Congress to roll back the stricter rules.

“In addition to significantly increasing administrative costs for states, the … provision has put up barriers for many eligible recipients and created a situation where U.S. citizens actually have fewer rights than non-citizens when applying for Medicaid benefits,” he wrote to congressional leaders in June.

Bruce Goldberg, director of the Oregon Department of Human Services, echoed those concerns while in Washington, D.C., last week. He said the law had the “opposite effect as the intent.”

His agency reviewed the 1,011 Oregonians who lost benefits during the first six months the policy was in effect. The survey found 91 percent of those who lost benefits spoke English, most of them were in households where other people qualified for help and almost all were believed to be U.S. citizens.

Peggy Cook, Idaho’s Medicaid program manager, said only 980 people (out of 175,000 beneficiaries) were denied for lack of documents in Idaho. Roughly a third of them later re-enrolled because they were able to prove their citizenship, she said.

At least 22 states reported that fewer people were on Medicaid nearly a year after the new rules took effect, according to a June report by the federal Government Accountability Office (GAO).

Because the law requires enrollees to show original documents, it makes it difficult to apply for Medicaid on the phone or online. GAO auditors concluded that states that previously allowed people to sign up by phone or computer were more likely to see enrollment drops than states that already required applicants to show up in person.

But often, it’s tough to pinpoint whether it’s the documentation rule or some other factor responsible for the declines.

Arizona reports the new documentation rules led to 2,883 Medicaid patients dropped from the rolls and the denial of benefits to 514 new applicants.

In Utah, enrollment has declined, but state officials say that’s the effect of a stronger economy. They said the dip there corresponded with a decline in the number of people receiving welfare benefits and getting food stamps.

Evidence in Virginia points to something other than the economy at work, because, at the same time Medicaid dropped 11,000 kids through March, the count of Virginia children on the SCHIP rolls increased by 2,000.

Medicaid enrollment in Minnesota actually increased from 502,000 in June 2006 to roughly 515,000 a year later.

The federal agency that oversees Medicaid said it does not yet have national enrollment figures for the last year, nor has it determined what effect the 2006 law has had on enrollment.

“We do not have any empirical data that unambiguously links any one policy to any particular change in enrollment,” said Mary Kahn, a spokeswoman for the Centers for Medicare and Medicaid Services, which administers the Medicaid program.

Meanwhile, 15 states set aside a total of $28 million to hire more workers to handle the more stringent background checks and to retrain existing staffers, according to the GAO. Many of those expenses are expected to continue through the current budget year.

For example, Kansas lawmakers set aside $1.4 million to clear a four-month backlog for both Medicaid and SCHIP applicants that came as a result of the new rules, said Megan Ingmire, a spokeswoman for the Kansas Health Policy Authority. Both programs were affected, because the same workers handled applications from Medicaid and SCHIP, even though the requirements were different. 

A survey in Colorado found that the rules are confusing, even for the workers who must sign up Medicaid applicants.

According to the Colorado Health Institute, front-line staffers didn’t know all of the documents that count as proof of citizenship under the law and frequently asked people who weren’t subject to the rules for the additional documentation.