Psychiatr News August 18, 2006
Volume 41, Number 16, page 1
© 2006 American Psychiatric Association
Need to Prove Citizenship Could Penalize Medicaid Recipients
Rich Daly
The impact of the tentative proof-of-citizenship rule Congress is imposing
on Medicaid beneficiaries has been softened, but advocates want further steps
to protect those with mental illness.
APA hopes it can convince the federal government to modify a new rule
requiring Medicaid beneficiaries to prove citizenship and identity before
beneficiaries with mental illness start confronting loss of coverage.
The policy, mandated by the Deficit Reduction Act (DRA) enacted in
February, was scheduled to be implemented by the Centers for Medicare and
Medicaid Services (CMS) in early July. However, CMS continued to develop
implementation plans after the intended start date. The final regulations were
expected to be released in mid-August.
Documents that can be used to prove citizenship include a U.S. passport,
certificate of U.S. naturalization, and certificate of U.S. citizenship. Other
documents—such as a U.S. birth certificate or official military record
of service showing a U.S. place of birth—are acceptable when accompanied
by proof of identity.
In the past, most states allowed beneficiaries to attest to U.S.
citizenship under penalty of perjury. Documentation was required only from
those whose citizenship status was in doubt
Congress enacted the new requirement over concerns that illegal immigrants
were falsely claiming citizenship to receive Medicaid benefits, although the
Office of Inspector General at the Department of Health and Human Services
found no substantial evidence of such problems.
APA applauded the decision by CMS in early July to allow states to exempt
the approximately 8 million people already enrolled in Supplemental Security
income or Medicare programs. Most states have opted to take that
less-restrictive route.
Critics of the citizenship policy, including APA, said that it endangers
the health care of about 40 million recipients not included in the
exemption.
"Requiring paperwork for people who are seriously and persistently
mentally ill is not very realistic," said Lizbet Boroughs, deputy
director of APA's Department of Government Relations. "Someone who has
been in and out of homeless shelters for years probably does not have a
driver's license, has long since lost his Social Security card, and I'm sure
is not walking around with a copy of his high school diploma."
Among the categories of beneficiaries with which mental health advocates
are most concerned are foster children, who are generally eligible for
Medicaid and have high rates of both medical and mental health problems but
have difficulty documenting citizenship. Others at risk of losing their
benefits are applicants who are found eligible for the Social Security
Disability Income or Medicare programs, but who are still in the waiting
period for those programs.
The regulations require states to help applicants with an "incapacity
of mind or body" to locate citizenship documents when applicants cannot
comply quickly and lack a representative to assist them. Such individuals
include those who have amnesia, mental illness, or physical incapacity.
According to CMS, states also can document citizenship and identity through
data matches with state-government agencies, such as with school records, to
establish the identity of children. If documentation is unavailable, CMS may
accept signed affidavits from two citizens—one of whom cannot be related
to the applicant—who "have specific knowledge" of a
beneficiary's citizenship status.
The agency noted that current beneficiaries should not lose benefits while
making "a good-faith effort to provide documentation to the
state."
APA has urged modifications of the rule through its partnership with the
Campaign for Mental Health Reform. In a letter in May to CMS, the campaign
urged the agency to allow "a broad list of other documents that may be
used to demonstrate citizenship, particularly those accepted by other federal
agencies, including the Social Security Administration and the Department of
Justice."
William Emmet, interim director of the campaign, said CMS's decision to
give states some discretion in determining which applicants meet the
proof-of-citizenship standard was a positive step and that he hoped for
similar latitude in the agency's final rules.
"Our concern all along was that people with mental illnesses and
other disabilities—people who are aged and infirmed with mental illness,
for example—are the most at risk, but the feds have left the door open
for the states to provide the kinds of assistance that those folks may
need," Emmet told Psychiatric News.
"It is critically important that remedial action occurs quickly... so
that Medicaid beneficiaries don't lose their health lifeline."
APA also is coordinating with the bipartisan National Governors
Asssociation, which is engaging in talks with federal officials responsible
for implementing the law.
Opponents of the documentation requirements have filed a class-action
lawsuit challenging the change from previous requirements.
"It is critically important that remedial action occurs quickly,
either by the Congress repealing the law or the federal district court
enjoining it, so that Medicaid beneficiaries don't lose their health
lifeline," said Ron Pollack, executive director of Families USA, which
is assisting with the lawsuit.
Opponents of the requirement estimate that approximately 3 million to 5
million low-income people may lose their Medicaid benefits because they are
unable to produce the required documents. Hospitals are still required to
provide emergency care regardless of whether individuals meet the
documentation requirement.
The CMS letter is posted at
<www.familiesusa.org/assets/pdfs/Fact-Sheet-Citizenship.pdf>.
The proof-of-citizenship requirements are posted at
<www.cms.hhs.gov/MedicaidEligibility/05_ProofofCitizenship.asp#TopOfPage>.
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