1. Effect of Medicaid citizenship documentation requirements in a family planning waiver: First year observations Lisa Angus Policy & Research Analyst Oregon Public Health Division, Reproductive Health June 10, 2008

2. Family planning Medicaid waivers FP waivers currently operating in 26 states Expansions mostly income-based; a minority extend length of coverage postpartum or in other situations Services include annual exams, birth control counseling and methods, other “contraceptive management” Federal financial participation for FP services at 90% but waivers must be budget neutral Recent evaluations find that FP waivers prevent unintended pregnancies and are cost-saving/cost-neutral

3. Medicaid citizenship documentation Provision of the 2005 Deficit Reduction Act (DRA) U.S. citizens applying for or renewing Medicaid coverage required to present “satisfactory documentary evidence” of citizenship Acceptable documents: –U.S. Passport; Certificate of Naturalization; U.S. Birth Certificate + photo ID (drivers license); others Little previous evidence of Medicaid fraud by non- citizens

4. Implementing DRA in Oregon’s FP waiver Waiver (FPEP) context: –Income-based waiver (up to 185% FPL) since 1999 –Point-of-service enrollment –Approx. 100,000 clients/year served at 160 local clinics DRA implementation concurrent with mandatory collection of SSN from teen applicants New, state-funded ‘one-time exception’ visits introduced as remedy for citizenship documentation requirements –Regular service; clients return later with documentation –Preserves same-day services for clients and reimbursement for safety-net providers

5. Analytic design & data Primary data source is Clinic Visit Record (CVR) for each family planning visit, including: –Patient demographics, medical & counseling services provided, birth control use, and visit source of pay CVR data used for bivariate comparisons of visit volume, payment source, and client characteristics before and after DRA Secondary analyses: trends in provider payments; return rate after one-time exception visits

6. Monthly visits by source of pay June 2006: Citizenship doc. rules announced Nov 2006: FPEP implements DRA

7. Monthly visits by source of pay excluding one-time exception visits June 2006: Citizenship doc. rules announced Nov 2006: FPEP implements DRA

8. % Change in FPEP visits by age group # FPEP VisitsUnder 1818-1920-2425-2930 plus 12 months pre-DRA25,05829,70062,33725,74522,444 12 months post-DRA14,43219,83345,13620,60616,362

9. % Change in FPEP visits by race # FPEP VisitsAfrican-AmericanAsian / PIWhiteAll Other 12 months pre-DRA2,8484,365145,7846,228 12 months post-DRA1,6333,074102,3854,612 African-American clients younger, on average, than other clients

10. % Change in FPEP visits by ethnicity # FPEP VisitsHispanicNon-Hispanic 12 months pre-DRA14,759150,468 12 months post-DRA10,050106,295

11. FPEP return rate for teens, by SSN status (Among teens with 1+ FPEP visit in year prior to DRA) Had FPEP visit in year post DRA Gave SSN voluntarily at pre-DRA FPEP visit54.0% (14,910 / 27,594) Did not give SSN at pre-DRA FPEP visit38.8% (3,003 / 7,734)

12. Uncompensated visits as % of total over time (At Title X-funded / safety-net clinics only)

13. FPEP provider payments by quarter March 2007: FPEP visit rate increases from $105 to $140

14. One-time exception usage and cost Month# One-times November (2006)2,602 December2,462 January (2007)2,444 February1,864 March1,575 April0 May330 June1,147 July1,103 August1,318 September1,154 October1,364 Usage heaviest among teens 65% of clients with one- time visits return with documentation Visit cost approx. $170 Cost of Medicaid birth in Oregon approx. $6200 State costs recouped if 467 clients avoid unintended Medicaid birth

15. Implications for FPEP clients & clinics For clients –Most dramatic impact is among teens, arguably the group most in need of confidential, same-day service –Delayed or foregone care or use of less effective, non- prescription birth control may lead to increased teen and unintended pregnancies – further study needed For clinics –Drop in FPEP visits represents a significant loss of revenue for safety-net clinics –Reports of reductions in operating hours, walk-in appointments, and staffing levels; 15 clinics closed

16. Implications for Medicaid policy & programs In the case of family planning waivers, citizenship documentation requirements unlikely to reduce spending –Federal spending down in short-term due to decreased waiver utilization among likely citizens, but state and local systems incur greater costs –Federal spending likely to increase over long term if Medicaid births increase for citizens or non-citizens Scale of impact may only be generalizable to programs with simplified and/or point-of-service enrollment Direction of impact and the populations most affected have broader relevance