Washington, D.C. - Congresswoman Hilda L. Solis (CA-32), joined by 48 Members of Congress, urged the Centers for Medicare and Medicaid Services to amend the interim final rule for the new proof of citizenship requirement for Medicaid eligibility.   

On July 7th, 2006, CMS released their interim final rule for implementation of the new citizenship documentation requirements for Medicaid services. The interim rule will shift the cost burden to low-income families, potentially eliminating coverage for those most in need and consequently increase the number of uninsured.

Estimates from the Center on Budget and Policy Priorities reveal that between 1.2 and 2.3 million U.S.-born citizens, including about 600,000 to 1.6 million children and 500,000 to 600,000 adults, may have serious problems obtaining or retaining their Medicaid coverage because they lack a birth certificate or passport. 

CMS should address these concerns in the final regulations to ensure that eligible individuals will not face additional barriers to care.

Below is the text of the letter: 

August 10, 2006

Mark McClellan, M.D., Ph.D.

Administrator

Centers for Medicare and Medicaid Services

200 Independence Avenue, SW

Washington, D.C. 20201

Dear Dr. McClellan:

We are writing to express our concern with the new citizenship documentation requirements for Medicaid services. The changes revealed in the July 7th release of the interim final rule do not eliminate the devastating impact that the provision will have on the health coverage of millions of Medicaid beneficiaries and applicants.  As a result, between 1.2 and 2.3 million U.S.-born citizens, including between 600,000 and 1.6 million children and 500,000 to 600,000 adults are at risk of losing their coverage because they do not have a passport or birth certificate readily available.

As drafted, the interim final rule risks delaying needed care. In the interim final rule, the Secretary affords current beneficiaries, at their next redetermination of eligibility, a "reasonable opportunity" to provide documentation of citizenship before they may be terminated from coverage.  However, this opportunity is not afforded to applicants who otherwise qualify for Medicaid and who self-attest that they are citizens.  We believe the regulations should permit states to begin providing coverage to eligible citizens based on their sworn declaration of citizenship, and to then afford them a reasonable opportunity to provide the necessary documentation. 

In addition, there are certain populations that need to be afforded special consideration.   In the interim final rule, CMS exempts Medicare beneficiaries; and, in most states, SSI recipients from the Medicaid citizenship documentation requirements.  However, it is a grave disservice not to similarly exempt children in foster care who are receiving assistance under title IV-E.  Under current law, title IV-E agencies are required to verify the citizenship of children prior to their being found eligible, and once that eligibility has been established the children automatically qualify for Medicaid. The Secretary has the discretion to exempt individuals from the documentation requirements if he finds other satisfactory documentary evidence of citizenship. We believe that the Secretary should use this discretion and permit state Medicaid agencies to accept the IV-E agency’s verification of citizenship, so as not to jeopardize care of these vulnerable populations.

Additionally, the interim final regulations needlessly jeopardize the health care of newborns, all of whom require immediate well-baby care and many of whom (i.e., those born prematurely or at low birth weight) require more intensive care.  Despite the fact that all children born in the United States are citizens, the interim final regulations do not permit states to consider a record of Medicaid (or other insurance) payment for the birth of a child as acceptable documentation of citizenship.  We believe this will unnecessarily delay needed care for newborn children and may risk their long term health. We strongly encourage the Secretary to make the necessary changes to ensure the health and well-being of these children, including permitting states to accept a record of Medicaid payment (or other insurance payment) for the birth of a child born in the U.S. as proof of citizenship and a medical record of birth in a U.S. hospital or other setting as secondary evidence of citizenship for children under six.

Finally, there are many other U.S. citizens and nationals for whom the citizenship documentation requirements will pose an extreme hardship and which will result in a denial of critical coverage.  These include victims of hurricanes and natural disasters whose records have been destroyed, homeless individuals, and naturalized citizens who have lost their certificate of naturalization.  In addition, Native Americans, other than a few select tribes, are currently not allowed to use tribal enrollment cards as primary evidence of citizenship. We believe the Secretary should exercise discretion to give states flexibility to use alternative methods to verify citizenship or identify “special circumstances” when the state finds that compliance with the regulations would be a hardship and the state has reasonable grounds to conclude that the individual is a citizen.

Fundamentally, the interim final rule does nothing but shift the burden to families of modest means and risk denying coverage to millions of needy women and children. The rule, as written, will leave States with its citizens delaying necessary healthcare, families struggling to obtain documentation, and financially strained community-based organizations and health clinics torn between providing care and turning patients away.  We strongly urge the Secretary to consider our suggestions and concerns, and only finalize this rule if it is determined that individuals otherwise eligible for Medicaid will not face increased barriers to quality healthcare that they deserve.

We thank you for your consideration and we look forward to working with you to help improve the health of our communities.

Sincerely,

Hon. HILDA L. SOLIS                                              Hon. DIANA DeGETTE

Hon. HENRY A. WAXMAN                                      Hon. SHEILA JACKSON-LEE

Hon. GRACE F. NAPOLITANO                                Hon. ROSA DeLAURO

Hon. JOE BACA                                                     Hon. LOIS CAPP       

Hon. RAUL GRIJALVA                                            Hon. PATRICK KENNEDY

Hon. LUCILLE ROYBAL-ALLARD                             Hon. FRANK PALLONE

Hon. XAVIER BECERRA                                         Hon. BOBBY L. RUSH

Hon. DENNIS CARDOZA                                         Hon. EDOLPHUS TOWNS

Hon. JIM COSTA                                                     Hon. JIM MORAN

Hon. HENRY CUELLAR                                           Hon. EARL BLUMENAUER

Hon. CHARLES A. GONZALEZ                                Hon. GENE GREEN

Hon. LUIS V. GUTIERREZ                                        Hon. JANE HARMAN

Hon. RUBEN HINOJOSA                                          Hon. BETTY McCOLLUM

Hon. SOLOMON ORTIZ                                            Hon. GWEN MOORE

Hon. ED PASTOR                                                    Hon. SAM FARR

Hon. SILVESTRE REYES                                        Hon. TAMMY BALDWIN

Hon. JOHN T. SALAZAR                                           Hon. JIM McDERMOTT

Hon. LINDA T. SANCHEZ                                         Hon. JOHN LARSON

Hon. LORETTA SANCHEZ                                       Hon. JAY INSLEE

Hon. JOSE SERRANO                                            Hon. MICHAEL E. CAPUANO

Hon. NYDIA VELAZQUEZ                                        Hon. MICHAEL M. HONDA

Hon. JANICE D. SCHAKOWSKY                             Hon. JOHN W. OLVER

Hon. ALBERT R. WYNN                                          Hon. BARBARA LEE

Hon. MADELEINE Z. BORDALLO                            Hon. HOWARD BERMAN

Hon. DENNIS KUCINICH