Order Code RS22629
March 22, 2007
Medicaid Citizenship Documentation
April Grady
Analyst in Social Legislation
Domestic Social Policy Division
Summary
Due to recent changes in federal Medicaid law, individuals who declare that they
are citizens must present documentation that (1) proves citizenship and (2) documents
personal identity. This Medicaid citizenship documentation requirement was included
in the Deficit Reduction Act of 2005 (P.L. 109-171) and modified by the Tax Relief and
Health Care Act of 2006 (P.L. 109-432). This report discusses issues related to the
documentation requirement that have received considerable media and interest group
attention, as well as proposed legislation (including H.R. 210, H.R. 1238, H.R. 1328,
H.R. 1535, S. 751, and S. 909 in the 110th Congress) that would modify or repeal the
requirement. It will be updated periodically to reflect significant legislative or other
activity.
Overview of Citizenship Requirements for Medicaid
To be eligible for the full range of benefits offered under Medicaid, an individual
must be a citizen or national1 of the United States or a qualified alien.2 Nonqualified
aliens can only receive limited emergency Medicaid benefits (all discussion in this report
will refer to full Medicaid, unless otherwise noted).3 Regardless of citizenship status,
individuals must meet all other eligibility requirements to qualify for the program.
1 Throughout this report, references to citizens also include nationals.
2 The term qualified alien was created by P.L. 104-193. Examples include legal permanent
residents (LPRs), refugees, and asylees. LPRs entering after August 22, 1996, are barred from
receiving full Medicaid benefits for five years, after which coverage becomes a state option.
3 Examples of nonqualified aliens include those who are unauthorized or illegally present and
nonimmigrants who are admitted for a temporary purpose. See CRS Report RL31630, Federal
Funding for Unauthorized Aliens’ Emergency Medical Expenses, by Alison Siskin, and CRS
Report RL33809, Noncitizen Eligibility for Federal Public Assistance: Policy Overview and
Trends, by Ruth Ellen Wasem.

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Since 1986, states have been required to obtain a written declaration, under penalty
of perjury, stating whether individuals applying for full Medicaid benefits are U.S.
citizens or nationals. Individuals who declare that they are not citizens have also been
required since 1986 to present documentation that indicates a “satisfactory immigration
status.” States must verify this documentation with the U.S. Citizenship and Immigration
Services Bureau of the Department of Homeland Security.
Due to recent changes in federal law, individuals who declare that they are citizens
must present documentation that (1) proves citizenship and (2) documents personal
identity in order for states to receive federal Medicaid reimbursement for services
provided them. This citizenship documentation requirement was included in the Deficit
Reduction Act of 2005 (DRA, P.L. 109-171) and modified by the Tax Relief and Health
Care Act of 2006 (TRHCA, P.L. 109-432). It applies to Medicaid eligibility
determinations and redeterminations made on or after July 1, 2006, and is a one-time
activity (once a person presents documentation, the state must retain the information for
future use). The law specifies documents that are acceptable for this purpose and exempts
certain groups from the requirement, including people who receive Medicare benefits,
Social Security benefits on the basis of a disability, Supplemental Security Income (SSI)
benefits, child welfare assistance under Title IV-B of the Social Security Act, or adoption
or foster care assistance under Title IV-E of the Social Security Act. Before the DRA,
states could accept self-declaration of citizenship for Medicaid, although some chose to
require additional supporting evidence.4
The citizenship documentation requirement does not apply to the State Children’s
Health Insurance Program (SCHIP). However, states that opt to cover SCHIP enrollees
under Medicaid may use the same eligibility form for all applicants. As a result, it is
possible that some SCHIP enrollees would be asked to present evidence of citizenship.
Citizenship Documentation Issues
Proponents of the new citizenship documentation requirement say that it will deter
unauthorized aliens and other ineligible noncitizens from obtaining full Medicaid benefits
by falsely claiming to be citizens; that it levels the playing field by holding citizens to the
same documentation standards as noncitizens; and that the burden on individuals should
be minimal because similar documentation is required in other settings (such as obtaining
a driver’s license). Opponents say there is little evidence that noncitizen fraud has been
a problem; that many eligible individuals will experience delayed or denied enrollment
because they do not have the necessary documents on hand; and that the requirement is
burdensome for states. Since enactment of the DRA and the publication of an interim
final rule in July 2006,5 a number of issues related to the requirement have received
considerable media and interest group attention. Some of the most prominent issues are
discussed below.
4 Department of Health and Human Services, Office of Inspector General, Self-Declaration of
U.S. Citizenship for Medicaid, OEI-02-03-00190, July 2005.
5 See Federal Register 71, no. 133, July 12, 2006 and [http://www.cms.hhs.gov/Medicaid
Eligibility/05_ProofofCitizenship.asp].

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Newborns. Under a provision of federal law that predates the citizenship
documentation requirement, a child born to a woman eligible for and receiving Medicaid
on the date of the child’s birth is automatically deemed eligible for Medicaid for one year,
so long as the child is a member of the mother’s household and the mother remains (or
would remain if pregnant) eligible for Medicaid.6 At the end of the year, the child’s
eligibility must be redetermined. As a result of the new citizenship documentation
requirement, which does not provide an exception for newborns, the child’s citizenship
also must be documented as part of the redetermination.
In the past, at least 20 states chose to deem eligibility for children — who are U.S.
citizens by virtue of their birth in the United States7 — born to noncitizen women on
emergency Medicaid (as they did for children born to women receiving full Medicaid
benefits).8 However, in the preamble to the interim final rule on citizenship
documentation issued last year, CMS stated that children born to women on emergency
Medicaid should not be deemed eligible because the mother would not remain eligible for
Medicaid if pregnant; therefore a Medicaid application must be filed for the newborn
(who is likely to qualify for coverage through a poverty-related eligibility pathway), and
the child’s U.S. citizenship must be documented. CMS changed its position in a press
release dated March 20, 2007, stating that it would modify this policy in an interim final
rule to be issued shortly, and that “[a]ny newborn whose mother files an application and
is determined eligible for emergency Medicaid ... could be deemed eligible for the first
year of life.”9 As with other deemed eligible newborns, citizenship documentation would
be required when the child’s eligibility is redetermined at the end of the year.
A number of groups had expressed concern that the previous CMS interpretation of
the deemed eligibility statute could impede access to care for newborns by delaying their
Medicaid enrollment and increasing the chances that a health care provider would refuse
to see them because they lack insurance coverage. To bridge the coverage gap between
Medicaid application and approval, states can opt to use presumptive eligibility (an option
in federal statute that allows certain individuals to receive temporary coverage while their
application is processed) for children. However, states must do so for all children under
age 19, making it potentially unattractive to those that would prefer to target a specific age
group such as newborns. Under another provision of federal law, states must provide
retroactive coverage for individuals who would have been eligible in the three months
6 Section 1902(e)(4) of the Social Security Act. CMS notes in its State Medicaid Manual that an
infant’s deemed eligibility is never affected by changes in income, because even if the infant’s
mother loses eligibility during the one-year period following birth, she would remain eligible if
pregnant (states are required to continue Medicaid coverage through pregnancy and a postpartum
period for pregnant women who would otherwise lose eligibility due to a change in income).
7 CRS Report RL33079, U.S. Citizenship of Persons Born in the United States to Alien Parents,
by Margaret Mikyung Lee.
8 National Health Law Program, State Responses to the CMS Policy Change on Medicaid
Coverage for Newborns, September 2006.
9 CMS, “All Low-Income Newborns to Receive Equal Access to Medicaid,” Mar. 20, 2007,
available at [http://www.cms.hhs.gov/apps/media/press_releases.asp].

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prior to their application for Medicaid.10 This allows health care providers to receive
reimbursement — albeit on a delayed schedule — for services provided before a Medicaid
application is approved.
Although deemed eligibility may no longer be an issue, some still assert that a child
whose birth occurs in a U.S. hospital and is paid for by the Medicaid program should be
entirely exempt from the citizenship documentation requirement. For these children, the
argument is that a state’s own Medicaid records should be evidence enough to prove that
they are U.S. citizens.
Reasonable Opportunity. Citizens and noncitizens appear to face disparate
treatment when it comes to the availability of Medicaid benefits before evidence of
citizenship or immigration status has been presented. Although the interim final rule on
citizenship documentation requires states to provide citizens with a reasonable
opportunity to present evidence before taking action on their Medicaid eligibility,
language in the preamble to the rule states that citizen applicants should not be made
eligible until they have presented the required citizenship documentation.
Federal law also requires states to provide noncitizens with a reasonable opportunity
to present evidence. However, unlike the interim final rule on documentation for citizens,
states may not delay, deny, reduce, or terminate Medicaid benefits for a noncitizen on the
basis of immigration status until the reasonable opportunity has been provided.11
Acceptable Documents. Some have applauded the interim final rule for
expanding on the list of acceptable documents provided in the DRA and allowing states
to obtain documentation through electronic data matching. Others have argued for an
even broader list of acceptable documents, and expressed concern that the interim final
rule imposes restrictions not required by the DRA. For example, the rule requires all
documents to be originals or copies certified by the issuing agency. Although many states
have simplified their eligibility processes by allowing Medicaid applications and renewals
by mail, some argue that individuals may view a visit to a Medicaid office as their only
option when the alternatives include sending original documents — such as passports,
birth certificates, and driver’s licenses — through the mail with no guaranteed return, or
paying to obtain certified copies instead.
State Implementation. Although the citizenship documentation requirement took
effect on July 1, 2006, some states briefly delayed implementation, citing reasons such
as the need to train eligibility staff and adequately notify Medicaid recipients. California
had not yet implemented the requirement as of February 2007, but expected to send
detailed guidelines to staff within weeks.12 Despite the possibility that federal Medicaid
funds could be withheld from states for periods when they were not in compliance with
the law, a CMS spokeswoman has said it is unclear whether there is “zeal” to do so.13
10 Section 1902(a)(34) of the Social Security Act.
11 Section 1137(d)(4) of the Social Security Act.
12 Clea Benson, “Medi-Cal ID Rules Readied,” The Sacramento Bee, Feb. 25, 2007.
13 Ibid.

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Although comprehensive information is not currently available, a number of states
have reportedly experienced declines in Medicaid enrollment since the citizenship
documentation requirement was implemented.14 Among six states detailed in a recent
report,15 Wisconsin is the only one whose data tracking system is set up to identify denials
and terminations due to a lack of citizenship documentation. It reports that about 14,000
people had their Medicaid eligibility denied or terminated for this reason between August
and December of 2006. Circumstantial evidence is cited for the other five states to
support the assertion that enrollment drops are due to the citizenship documentation
requirement, rather than broader economic trends or changes in the employment of low-
income families. For example, caseloads for food stamps (a means-tested program whose
enrollment levels are sensitive to economic conditions) have reportedly risen in these
states, rather than fallen.
Even if most or all of the reported Medicaid enrollment declines are due to the
citizenship documentation requirement, a key question is whether the people who are
being denied or terminated are U.S. citizens, rather than unauthorized aliens or other
ineligible noncitizens. In Wisconsin, the report cited above found that about 70% of
people who were denied or terminated in the months following implementation had proof
of citizenship (assisted by electronic data matching with the state’s vital records agency),
but lacked an identity document. Medicaid officials in a number of other states have
indicated they believe that most of the people who account for recent enrollment declines
are U.S. citizens.
In addition, at least six states are projecting an increase in Medicaid administrative
costs due to the citizenship documentation requirement.16 States will be reimbursed for
these costs using the 50% federal matching rate that applies to most Medicaid
administrative functions. Since existing Medicaid enrollees must present citizenship
documentation at their next eligibility redetermination, administrative costs should peak
in the year following implementation of the requirement (eligibility redeterminations
occur at least once a year for most Medicaid enrollees). Administrative costs in later
years should be lower, reflecting the ongoing expense cost of documenting applicants who
are new to the program.17
14 For example, see Robert Pear, “Lacking Papers, Citizens Are Cut From Medicaid,” The New
York Times, Mar. 12, 2007.
15 Donna Cohen Ross, New Medicaid Citizenship Documentation Requirement Is Taking a Toll,
Center on Budget and Policy Priorities, Feb. 2, 2007.
16 Ibid.
17 In its cost estimate for the DRA, the Congressional Budget Office estimated that the citizenship
documentation requirement would result in 35,000 fewer enrollees (mostly illegal immigrants)
and reduce federal Medicaid spending by $735 million over 10 years. It is unclear whether the
estimate accounted for a potential increase in Medicaid administrative costs.

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Legislative and Other Activity
In the 110th Congress,18 six bills that would affect the Medicaid citizenship
documentation requirement have been introduced:
! H.R. 210 would exempt all children born to women on Medicaid
(including emergency Medicaid) from the citizenship documentation
requirement during their first year of life.
! H.R. 1238 would have the effect of permanently exempting all children
born to women on Medicaid (including emergency Medicaid) from the
citizenship documentation requirement by allowing a state’s own
Medicaid records to serve as proof of citizenship in cases where a child’s
birth is paid for by the program.
! H.R. 1328 would require additional documentation options for federally
recognized Indian tribes.
! S. 751 would explicitly require deemed eligibility and separate
identification numbers for children born to noncitizen mothers on
emergency Medicaid.19 It would also permanently exempt all children
who are deemed eligible for an automatic year of coverage from the
citizenship documentation requirement and allow states to provide
retroactive eligibility for newborns who were previously denied.
! H.R. 1535 and S. 909 would make Medicaid citizenship documentation
a state option. They would require states to use criteria that are no more
stringent than those used by the Social Security Administration, require
additional documentation options for federally recognized Indian tribes,
and specify the reasonable opportunity period for individuals who are
required to present documentation. They would also permanently exempt
all children who are deemed eligible for an automatic year of coverage
from the citizenship documentation requirement, and allow states to
provide retroactive eligibility for newborns who were previously denied.
In the absence of legislation, it is possible that some citizenship documentation
issues will be addressed through administrative or legal action. As described earlier,
CMS has announced it will act administratively to achieve a goal similar to that of H.R.
210. Prior to this announcement, the state of Washington had filed a lawsuit in an attempt
to block implementation of the citizenship documentation requirement for children born
to noncitizen mothers on emergency Medicaid, and to allow these children an automatic
year of coverage.20 Although H.R. 1238, H.R. 1535, S. 751, and S. 909 also contain
provisions intended to clarify that deemed eligibility applies to children born to noncitizen
women on emergency Medicaid, they would go beyond the anticipated CMS action by
permanently exempting all deemed eligible newborns from the citizenship documentation
requirement.
18 In the 109th Congress, three bills were introduced to repeal or delay implementation of the
Medicaid citizenship documentation requirement (S. 2305, S. 3590, and H.R. 5023). Two other
bills (S. 3524 and S. 4122) would have required additional documentation options for federally
recognized Indian tribes.
19 Under current law, services provided to newborns who are deemed eligible for a year of
coverage may be billed under their mother’s identification number.
20 David Ammons, “State Sues Feds Over Health Care for Infants of Immigrants,” The Seattle
Times, Mar. 6, 2007 and [http://www.governor.wa.gov/news/2007-03-02_complaint.pdf].

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