The Deficit Reduction Act's Citizenship Documentation Requirements for Medicaid Through the Eyes of State Officials in May and June 2008

Most states were unable to fully implement the Deficit Reduction Act of 2005 (DRA) citizenship and identity documentation requirements on the July 1, 2006, effective date of this new provision, and instead phased in implementation. A survey of state officials from Medicaid and combination Medicaid/State Children’s Health Insurance (SCHIP) programs in 43 states revealed that by mid-2008 three-quarters of states had fully implemented the DRA requirements for new Medicaid applications and 70 percent had implemented them for Medicaid renewals.

The DRA’s intent to screen out ineligible people from public coverage resulted in new enrollment barriers that created obstacles to the goal of the Covering Kids & Families® (CKF) initiative to enroll all eligible children into Medicaid/SCHIP. From the perspective of state officials, DRA limited CKF’s full potential and undermined some states’ earlier efforts to expand enrollment. It could also be argued, however, that without the presence of CKF and the tools and skills CKF had already imparted to state officials (Duchon and Ellis 2008), the negative effects of the DRA requirements on enrollment, as reported by state officials, would have been even greater.

Most states implemented new education and outreach initiatives to inform clients, community organizations and providers of the DRA requirements. To streamline the process of citizenship documentation, 39 of 43 states have implemented (including three with plans under way) an automated data match to secure birth records from their own vital records agency. For 24 states, these were new processes undertaken specifically to accommodate the DRA requirements. Many states also perform automated matches of identity data with their state Department of Motor Vehicles (DMV) and pay for in-state and out-of-state document requests. Many states have made concerted efforts to verify documentation electronically. These include the data matching strategies described above as well as parent attestation to the identity of a child by e-signature, to avoid the need for parents to apply in person for Medicaid or SCHIP for their children.

As of mid-2008, about half of officials representing Medicaid programs or combination Medicaid/SCHIP programs indicated that the DRA requirements had resulted in fewer eligible children and families enrolled in Medicaid. The SCHIP effect has been less dramatic, with just under one-third of programs reporting a reduction in enrollment of eligible children attributable to the DRA provisions. The majority of state officials with an opinion believed that the reductions were temporary. However, several officials expressed concern that deferred enrollments due to barriers created by the DRA requirements lead to more eligible children being without coverage until a medical emergency arises.