Update on Medicaid Citizenship Verification Activities

In this update, Voices is including several newly-released documents explaining the Medicaid citizenship documentation requirements and the effects those requirements are having upon families and states.  The first document was released earlier this month by the Center on Budget and Policy Priorities, describing data from three states that show the effect of cit doc based on race/ethnicity. In the paper, CBPP describes newly available data from three states (Alabama, Kansas, and Virginia), showing that white and African American children are much more likely than Hispanic children to have their Medicaid coverage delayed, denied, or terminated as a result of a citizenship documentation requirement that took effect last year.  These data provide further evidence that the requirement, purportedly aimed at preventing undocumented immigrants from improperly obtaining Medicaid, is instead overwhelmingly affecting U.S. citizens who are eligible for the program.  Ohio Health Plans (OHP) is currently reviewing Ohio data, and preliminary results are suggesting findings that are comparable to what is being reported in the three states that are the subject of the CBPP paper. Voices will provide results as soon as they become available.

Additional documents were just released, and provide some additional helpful analysis. The GAO report entitled "States Reported That Citizenship Documentation Requirement Resulted in Enrollment Declines for Eligible Citizens and Posed Administrative Burdens".  CMS has already criticized the report, saying that the state Medicaid offices that provided the information could not back up their assertions with hard data. The other report is an analysis by the majority staff of the House Committee on Oversight and Government Reform, which looked at nine states to assess whether the cit doc requirements have achieved the goal of saving the taxpayer money by excluding undocumented immigrants from Medicaid coverage.  (They found that states are spending millions and saving very little.)

Mary Wachtel, Voices Director of Public Policy and Tom Scheid, Consultant to Voices, met with staff from Ohio Health Plan several weeks ago to discuss the recommendations that Voices had made for improvements in the implementation of the Medicaid citizenship documentation requirements.  These recommendations were based on the work in the Monitoring Project, and the discussions with all who have been participating in the Stakeholders meetings.  The discussion focused upon four main recommendations, as follows.

1. OHP should provide more direction, training, and policy clarification to counties to apply the full flexibility of the federal and state regulations.
2. OHP should put more of a priority on aggressive use of electronic data-matching.
3. All Medicaid denials or terminations due to lack of citizenship documentation should be re-run by the State against the electronic data file of Ohio births.
4. Third parties such as health care providers should be given the ability to verify original citizenship documents.

OHP noted that they knew there were still a lot of problems with out-of-state birth certificates, and problems with counties wanting to waiting longer that 30 days before considering accepting documentation at the third or fourth tiers. They said they were unaware that additional training to counties was needed, but were open to ideas.  Voices pushed for ongoing training and technical assistance, based upon the types of implementation problems that they have been receiving through their own HelpDesk. There was discussion and agreement that the next video conferences could include advocates, and that some issues should be more aggressively and directly communicated to county directors (including using the Ohio Job and Family Services Directors' Association, which has offered to help).  Voices is expecting a follow-up meeting with counties, advocates, etc. to identify in some detail the current areas of confusion/miscommunication that should be addressed through additional training and communication from the State.

OHP said they were working on obtaining data sharing agreements, which should help greatly with the out-of-state birth certificates, but no details were available to indicate when any agreements would be in place.  The on-line access to Ohio birth certificates is now fully operational, but only dating back to births in 1983 and does not include the approximate 5000 per year that are on “hold” because the mother will not name the father and the father is not the husband of the woman.  OHP reported that they are moving ahead with the project to electronically notify all managed care plans of upcoming Medicaid redeterminations, although they do not yet have a date when the notifications will start going out to the plans.  Still, it is very encouraging that despite the administrative budget costs, they recognize the importance of this and are moving forward to honor their promise.  OHP also noted that a website has now been released to counties that can be accessed to verify Identification through BMV records.  Voices is in the process of checking to see how widely known it is to caseworkers that they now have easy access to BMV as a source of identification. 

OHP, as well as some counties, have been doing case reviews to determine the appropriateness of denials due to cit doc.  They are finding over half of all denials are subsequently approved with no gap in coverage.  They are still looking at the feasibility of the state running all denials against the birth certificate data base,  but will be taking into consideration whether it is likely at this late date that they will find very many denials based just on lack of a birth certificate that can now be verified electronically. 

Voices wasn't able to obtain much new insight into how OHP is looking at third party verifications, but the meeting did provide an opportunity to explain in fuller detail how it works in other states, that Voices believes current rules would allow it in Ohio, and that it could be designed in a way that further reduces the stress upon families and upon county eligibility workers.