Presentation on theme: "Center for Public Policy Priorities www.cppp.org 1 Medicaid Citizenship Documentation: Medicaid Citizenship Documentation: State-level Advocates Can Help."— Presentation transcript:
Center for Public Policy Priorities 1 Medicaid Citizenship Documentation: Medicaid Citizenship Documentation: State-level Advocates Can Help Monitor Impact, Help Minimize Barriers, and Make the Case for Reform Families USA January 25, 2007 Anne Dunkelberg, Associate Director 900 Lydia Street - Austin, Texas Phone (512) – fax (512)
Center for Public Policy Priorities 2 Things You Can Do Learn the details of how YOUR state is implementing the federal Deficit Reduction Act requirements. –You may need to understand whether/how your state is being more or less flexible than strict/literal Fed Rules Help educate CBOs, health care providers about your states policy. Engage CBOs and providers in monitoring the impact of the requirements on clients/patients. Checklists, log forms may be helpful
Center for Public Policy Priorities 3 Things You Can Do Ask CBOs and providers to help clients access out-of- state Birth Certificates Collect real-people stories illustrating the problems US citizens face obtaining documents, any delays in care that result. Try Collegiality: MOST state Medicaid directors opposed this policy. (IF POSSIBLE!) pitch your focus on documenting need for changes in FEDERAL policy; offer to help your state officials identify and correct mis-application of policy in the field.
Center for Public Policy Priorities 4 Data Wish List to document enrollment and policy consequences (From GU-Health Policy Institute) 1.Monthly caseload 2.Ins and outs of enrollment 3.Proportion of applications denied 4.Proportion of failed renewals 5.Reasons for denials 6.Reasons for failed renewals 7.Gaps in coverage 8.Length of coverage prior to leaving program 9.Service use before and after gaps 10.Service costs before and after gaps
Center for Public Policy Priorities 5 More Data Ideals… Undermining use of mail-in app or renewal? Is Vital stat search being offered, automatic, or only on request? Is prior submission of birth certificate being checked, honored (one-time requirement)? Administrative cost to your state? Timeliness of apps and renewals -- taking longer? Meeting fed standards? –Are clients experiencing delays and gaps, then getting coverage? Any (improper) effect on Food Stamps? Costs to providers, CBOs to assist clients? COST OF OBTAINING BIRTH CERTIFICATES!!
Center for Public Policy Priorities 6 The Good News and Bad News So Far…. Good news: No individual problem cases reported to CPPP yet. HHSC responsive to hearing about problems with policy not being followed properly in field. Diverse provider groups and others willing to help track issue. BAD News: Denials of New Medicaid Applications for Citizenship Documentation, 8-06 thru AugSeptOct Pregnant Women Child < Child ,291 Child ,035 Adults (TANF level) ,4491,7733,767
Center for Public Policy Priorities 7 Denial Reason Jul-06Aug-06Sep-06Oct-06Nov-06Dec-06 8/06- 12/06 Excess Income13,00116,02713,52113,97821,02617,630 Refused to Provide Info9,77412,73512,85013,10718,11215,863 No Eligible Child4,2195,0074,1774,2506,0674,839 Appointment Not Kept8391, No Proof US Citizen05451,4491,7732,5303,4239,720 Voluntary Withdrawal1,1511,4331,2281,2041,6701,2974.3% Not US Citizen1,1531, ,2041,0985,385 Other3,3824,3433,8133,7515,4614,2402.4% Total Denials33,51942,36538,68839,59257,01649,088226,749 Total Applications131,934157,005135,142141,011199, ,20 4 Denial Rate25.4%27.0%28.6%28.1%28.6%30.1%
Center for Public Policy Priorities 8 Potential Partners, Sources of Information Physician groups, specialty groups, local medical societies Hospital groups or individual hospitals. –Childrens and major birthing centers –Hospital consultants who pursue Medicaid CBOs that do application/renewal assistance FQHCs, Family Planning Legal Aid, Family Violence, Health Advocates (of course) Aging, Disability Advocates
Center for Public Policy Priorities 9 Training Materials used with Texas Providers
Center for Public Policy Priorities 10 Federal DRA adds New Medicaid Document Requirement for U.S. Citizens CMS own research found that citizenship fraud is not a problem in Medicaid. In July, 2005, the Office of Inspector General of the USDHHS issued report that there was little evidence of citizenship fraud, and CMS officials indicated that they saw no reason for changes in documentation requirements.
Center for Public Policy Priorities 11 Federal DRA adds New Medicaid Document Requirement for U.S. Citizens Deficit Reduction Act of 2005 (DRA) (actually passed in 2006) provision effective July requires that U.S. citizens applying for or receiving Medicaid document their citizenship and identity. CMS own research found that citizenship fraud is not a problem in Medicaid. In July, 2005, the Office of Inspector General of the USDHHS issued report that there was little evidence of citizenship fraud, and CMS officials indicated that they saw no reason for changes in documentation requirements. Did NOT change eligibility or document requirements for NON- citizens and Medicaid. Fed rules excluded all Medicare and SSI beneficiaries from documentation requirement (i.e., MOST seniors and disabled in Medicaid population exempted). BUT same rules went well beyond the law and did things like require ID from infants and children. Fortunately, Texas HSC implementing this policy in as client-friendly a manner as possible.
Center for Public Policy Priorities 12 NOT a Change in Medicaid Policy for Immigrants Did NOT change eligibility or document requirements for NON-citizens and Medicaid: –Undocumented have never been eligible for full Medicaid (some Emergency bills, incl. labor & delivery, are covered for providers) –Since 1996, even Legal Permanent Residents (LPRs, green card) who arrived after 8/22/96 are excluded from Texas Medicaid. Note that pre-1996 entrants ARE still eligible. –LPR kids can get CHIP, up to same income limit as US citizen kids. –Medicaid LPRs have ALWAYS had to provide official immigration documents.
Center for Public Policy Priorities 13 BUT Mixed-Immigration Families are Affected. Confusion and fear may already be preventing US CITIZENS in mixed-immigration families from accessing health care and Food Stamps. –23 percent of ALL Texas' children live in "mixed families" (one or more parent is non-citizen) –34 percent of Texas' children in low-income families (<200% FPL) are in mixed families (Census 2001 CPS, CBPP) –Food Stamp enrollment by lawful permanent residents has declined 21% statewide since December 2005
Center for Public Policy Priorities 14 Bad Law; Worse Fed Rules CMS July Interim Final Rules rules go well beyond what the DRA either requires or authorizes. Examples of Problematic requirements in rule that were not in law: New applicants dont have as long to get documents as renewing enrollees – no benefits until documents received Did not exempt kids in IV-E Foster Care Requires ALL CHILDREN to provide ID documents; i.e., birth certificate not enough –Does NOT recognize states own Medicaid birth records, or other hospital birth records as primary proof of US citizenship Directs states to treat US citizens newborns of immigrant moms different from US citizens newborns of US citizen moms.
Center for Public Policy Priorities 15 Bad Law; Worse Fed Rules No Family Planning Waiver exception. Expects states to actually inspect original ID documents, despite movement away from in-person interviews, higher use of mail-in (about 1.5 of the 1.75 million kids on Texas Medicaid can use mail application & renewal). Sets up complicated 4-level hierarchy of acceptable documents. Requires that many documents be at least 5 years old to be used – even for infants and young children!
Center for Public Policy Priorities 16 Positive Provisions of Fed Rules Excluded all Medicare and SSI beneficiaries from documentation requirement (i.e., MOST seniors and disabled in Medicaid population exempted). –A small population of adults with disabilities will still be subject to documentation. Approved states use of electronic vital stats databases instead of hard copy documents. Allows continued presumptive eligibility (not in use in Texas currently)
Center for Public Policy Priorities 17 Recent Changes to Fed Law Tax Relief and Health Care Act of 2006 (TRHCA) Clarified that these groups exempt from citizenship documentation requirements: citizens receiving Medicare, Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), children in any kind of foster care (i,.e., for whom child welfare services are made available under Title IV- B on the basis of being a child in foster care and children who receive foster care and adoption assistance payments under Title IV-E).
Center for Public Policy Priorities 18 Who is At Risk? Groups at risk for delays and denials despite being eligible (i.e., because they cant promptly access required documents), in rough order of risk and numbers. Risk is particularly higher if born in another state than Texas (and have to try to get a birth certificate from another state): Women applying for Medicaid maternity coverage. The fed rules say new applicants of all kinds CANNOT BE CERTIFIED until documentation is complete; BUT if HHSC succeeds in policy of NOT delaying certification, could be OK. Adult women applying for Texas pending Medicaid Family Planning Waiver Very poor Parents seeking Medicaid for themselves Non-elderly adults with disabilities seeking Community Attendant Services or other long term care under waivers (i.e., those who do NOT receive SSI and/or do not YET receive Medicare – 24 month delay from onset of SSDI and Medicare eligibility) Children applying for Medicaid (not born in Texas)