CMS issues citizenship guidelines to state Medicaid directors
On June 9, CMS issued the long-awaited guidelines for states to administer the provision in the Deficit Reduction Act of 2005 requiring individuals claiming U.S. citizenship when they apply for Medicaid to provide satisfactory documentary evidence of citizenship or nationality when initially applying for Medicaid or upon a recipient's first Medicaid redetermination on or after July 1, 2006.
The CMS letter to state Medicaid directors provides four charts with documents of varying levels of acceptability for establishing citizenship and one chart for documents establishing identity.
The law requires that for new Medicaid applicants or currently enrolled individuals, states must obtain evidence of citizenship at the time of application or the first redetermination on or after July 1, 2006. Recipients will need to provide documentation only once unless doubt is cast on the situation because once citizenship is established, it is a circumstance not likely to change, CMS said.
Thus, beginning July 1, self-attestation of citizenship by applicants or recipients was not acceptable. At the time of application or redetermination, states must give applicants or recipients who signed a declaration claiming to be a citizen, a "reasonable opportunity" to present documents establishing U.S. citizenship or nationality and identity.
Individuals who already are Medicaid recipients remain eligible until determined ineligible. CMS said a determination terminating eligibility may be made only after a recipient has been given a reasonable opportunity to present evidence of citizenship or the state determines the individual has not made a good-faith effort to present satisfactory documentary evidence of citizenship.
The guidance advises: 1) an individual who is already enrolled in Medicaid will remain eligible if he/she continuously shows a good-faith effort to present satisfactory evidence of citizenship and identity; 2) applicants for Medicaid should not be made eligible until they have presented the required evidence; 3) if an applicant or recipient tries in good faith to present satisfactory documentation, but is unable because the documents are not available, the state should assist the individual in securing these documents; and 4) if an applicant or recipient cannot obtain the necessary documents and needs assistance (i.e., is homeless, mentally impaired, or physically incapacitated), and lacks someone who can act on his or her behalf, then the state should assist the applicant or recipient to document U.S. citizenship and identity.
The letter also provides several state processes and best practices:
1. All documents must be either originals or copies certified by the issuing agency. Copies or notarized copies may not be accepted.
2. States must maintain copies in the case record or database and make them available for compliance audits.
3. States may permit applicants and recipients to submit such documentary evidence without appearing in person at a Medicaid office.
4. If documents are found to be inconsistent with pre-existing information, are counterfeit, or altered, states should investigate for potential fraud and abuse, including referral to the appropriate state and federal law enforcement agencies and/or the agency that issued the document.
5. Presentation of documentary evidence of citizenship is a one-time activity. Once a person's citizenship is documented and recorded in a state database, later eligibility changes should not require repeating the documentation of citizenship unless later evidence raises a question about citizenship.
6. A number of states — New York, New Hampshire, and Montana — have required documentation of citizenship for many years. New York and New Hampshire have published guidelines for documenting U.S. citizenship that generally mirror the list of acceptable documents in the letter. States with such a process currently in place to document citizenship should review the letter and modify their process as appropriate, CMS said.
CMS warns that federal matching funds will not be available if states don't require appellants and recipients to provide satisfactory documentary evidence of citizenship.
Before CMS issued its guidelines, states had been asking for more flexibility in implementing the requirement. While the law is intended to prevent undocumented immigrants from claiming to be citizens in order to receive benefits provided only to legal residents, states have said they worry that eligible Medicaid enrollees who cannot provide the necessary documentation also stand to lose coverage. State officials also fear the law will create a large administrative burden and confuse beneficiaries.
California Medicaid director Stan Rosenstein said he wants to use signed personal affidavits for young children and some adults on Medicaid who can't produce the required documents.
"We want to use as many alternative sources as possible," he said. But CMS administrator Mark McClellan said the agency wanted "to provide an effective way to document citizenship without placing excessive burdens on states or beneficiaries." We know that for some people it's going to take a little time, and we want to be able to account for that."
Download the CMS materials at www.cms.hhs.gov/MedicaidEligibility/05_ProofofCitizenship.asp.
On June 9, CMS issued the long-awaited guidelines for states to administer the provision in the Deficit Reduction Act of 2005 requiring individuals claiming U.S. citizenship when they apply for Medicaid to provide satisfactory documentary evidence of citizenship.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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