Government

Medicaid citizenship rule eased, but access concerns persist

Some physician groups say enforcement should be delayed until there are adequate and uniform guidelines.

By Amy Lynn Sorrel — Posted July 24, 2006

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The medical community is holding back sighs of relief over federal efforts to relax Medicaid's new proof-of-citizenship rules, fearing the mandate still could leave millions of the nation's low-income patients vulnerable to losing medical coverage.

The law, which took effect July 1, requires Medicaid patients, at the time of application or renewal, to prove that they are U.S. citizens or legal residents using a birth certificate, passport or other original identification records. Passed by Congress in February as part of the Deficit Reduction Act, the measure is intended to prevent undocumented immigrants from receiving Medicaid benefits.

But the potential impact has stirred up criticism, with many medical professionals and patient advocacy groups fearing that eligible patients will be confused and possibly dropped because they cannot produce the necessary paperwork. Citizenship was previously a condition for Medicaid; however, proof was only mandatory when that status was doubtful.

Shortly after a class-action lawsuit was filed June 28 challenging the law, the Centers for Medicare & Medicaid Services announced that elderly and disabled patients receiving Medicare or Supplemental Security Income would be exempt from the requirement because they already had to document their status. The new rules also outlined alternatives that states could use as verification, including electronic data matches with other government agencies, or, in rare circumstances, a written affidavit by two other citizens, one of whom must be unrelated to the applicant.

The government estimates the changes will exempt about 8 million of the 55 million Medicaid patients from the new rules.

While physicians agree that the exceptions are a step in the right direction, they say it is still not enough to ensure that other at-risk patients, such as foster children, the homeless, the mentally ill and disaster victims, can receive uninterrupted care while they seek documentation.

"It is still a burden on folks we fear are eligible and won't get treatment, and we are not clear there was any significant abuse of the system going on anyway," said California Medical Assn. spokesman Peter M. Warren.

Doctors say they are unsure about how the system will play out and suggest that enforcement should be delayed. "It has, for the physician community and organized medicine, caused a tremendous amount of confusion," Warren said.

For example, issues surrounding payment remain ambiguous. Unless federal regulations include specific provisions holding doctors harmless for treating patients believed to qualify for Medicaid, doctors are concerned that they could end up providing uncompensated care.

"Doctors are put in a quandary, and [the rules] could put a financial burden on physician clinics because the need for care doesn't just go away," said Carla Kakutani, MD, a family physician and president-elect of the California Academy of Family Physicians.

Dr. Kakutani said she still was unclear whether certain waiver programs that allow doctors to take new patients on the spot, usually for preventive care such as child immunizations, will be subject to documentation requirements.

Doctors say they are concerned that somewhere down the line, they will be responsible for a citizenship litmus test at the point of care.

"We should not be in the border patrol business," said internist Gary M. Wiltz, MD, medical director of the Teche Action Clinic, a federally funded community health center in Louisiana. About one-third of the clinic's approximately 12,000 patients are on Medicaid, according to Dr. Wiltz.

Those who cannot easily fulfill the documentation requirements, he said, likely will seek medical services in emergency departments, which are mandated to treat them. This would increase unpaid care. Even legal immigrants, who are eligible for certain Medicaid benefits, may be discouraged from applying, he added.

"We need to be very careful not to disenfranchise people," Dr. Wiltz warned. "There should be checks and balances, but this proposal is not well thought out."

AMA Executive Vice President and CEO Michael D. Maves, MD, MBA, wrote in a May letter to CMS that the initial guidelines could "create new hurdles for Medicaid applicants and recipients or result in delays in needed medical care and services."

According to CMS, patients should not lose benefits in an interim period as long as they are undertaking a good faith effort to provide documentation.

"We want the law to be the least burdensome possible to beneficiaries within the confines of the statute," said agency spokeswoman Mary Kahn. Even so, "states that are found not to be in compliance with this or any other Medicaid regulation are running the risk of losing their federal [matching funds]."

But states did not receive initial guidelines from the federal government until June 9 for the July 1 start date, California Dept. of Health Services Chief Deputy Director Tom McCaffrey pointed out.

"We expect we will have implementation by early August," he said.

A handful of other states also have delayed full application of the citizenship regulations because the rules came so late. Illinois Dept. of Healthcare and Family Services spokeswoman Kathleen Strand said, "We are going to make a good faith effort to comply with the law while ensuring that anyone who needs vital health care is going to get it."

It is unclear how the changes in the CMS regulations will affect the class-action lawsuit filed in a federal district court in Chicago. On July 6, the day CMS eased the rules, Judge Ronald A. Guzman scheduled a hearing for July 28 to "give all parties time to evaluate legal claims in light of the new regulations," said John Bouman, an attorney for the Sargent Shriver National Center on Poverty Law. The center filed the lawsuit along with three other advocacy groups.

"We are not out of the woods yet," Bouman said.

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ADDITIONAL INFORMATION

Case at a glance

Ruby Bell et. al v. Michael Leavitt, secretary of the U.S. Dept. of Health and Human Services

Venue: U.S. District Court for the Northern District of Illinois, Eastern Division, Chicago
At issue: Whether a federal law requiring Medicaid patients to prove their citizenship using documentation, such as passports, birth certificates and other original records, is constitutional.
Potential impact: The medical community says many low-income patients who are U.S. citizens could lose their Medicaid coverage because they do not have access to the necessary documents. The government says it has made certain exceptions and that patients should not lose their benefits as long as they are making a good-faith effort to provide documentation to their states.

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External links

Centers for Medicare & Medicaid Services' Medicaid proof-of-citizenship rules (link)

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