1. Citizenship documentation: Best Practices in the States Tactics to alleviate the burden and potential harm of the Medicaid citizenship & identity documentation requirement. Families USA 1/25/07

2. Families USA survey Reviewed published state policies for every state Interviewed advocates and Medicaid agency representatives about state policy Identified innovative strategies to lessen enrollment declines, help beneficiaries and applicants.

3. States policies comply CMS interim final regulations and minimize the burden on applicants through: I.Data matching II.Flexible definitions and timeframe III.Client assistance IV.Outreach to applicants, beneficiaries, and stakeholders V.Simplification of documentation requirement VI.State oversight of terminations

4. I. Data matching: CMS regulations allow states to use data matching to verify citizenship and/or identity of clients using these electronic databases: Social Security Administrations SDX database, State vital records databases, Federal or state government agencies.

5. States are effectively employing data matching to meet the requirement. Preemptive matching: State performs data matching prior to requesting documentation from beneficiaries. Centralized verification units: Medicaid agency forms state-level, centralized verification unit to perform data matches. Matching with state agencies: Medicaid agency interfaces with the DMV or Attorney Generals office to verify identity electronically. SDX database: Medicaid agency uses SDX to verify citizenship and identity for SSDI recipients and anyone who has ever applied for SSA benefits in the past.

6. II. Defining reasonable opportunity period and good faith effort: CMS requires states to provide a reasonable opportunity period for all individuals to obtain and submit documentation. Allow beneficiaries until next redetermination to submit documents: NH and VT provide one full year. Give applicants time beyond typical processing deadlines: NC pends applications for 6 months, system code triggers reminder letters periodically.

7. States must allow renewing enrollees to receive benefits and give applicants necessary extensions if they are making a good faith effort. Viewing evidence that beneficiaries/applicants have requested documentation is not necessary to prove good faith effort. In many states, as long as clients maintain contact and cooperate with the agency, Medicaid considers that they are complying, grants necessary extensions and provides assistance – AR, CT, MN, OK.

8. III. Assistance obtaining documents: CMS requires states to assist special populations (homeless, mentally impaired, physically incapacitated), but states should assist everyone. Assume full responsibility for obtaining documents on behalf of applicants and beneficiaries. Work with vital records to verify citizenship even if data matching is not possible.

9. IV. Strong outreach efforts: Many states have worked with community stakeholders to develop state rules, train eligibility staff and provide targeted information to applicants and beneficiaries. Targeted training: Arkansas trains clerical workers in field offices to verify documentation of clients present. Evening drop-in hours: District of Columbia holds evening drop-in hours once a week until 8pm in five of seven service centers. Hired documentation verification clerks for every center. Deputized centers: Virginia deputized the health department, health centers, and outreach programs to view and authenticate documentation. Contracting: New York contracts with community-based organizations to facilitate Medicaid enrollment. CBOs now help clients meet the requirement.

10. V. Simplification of the documentation requirement: CMS regulations specify a hierarchy of allowable documents, in order from most to least reliable. States can simplify the hierarchy. Straightforward, specific communications, Rapid procession through hierarchy, Attestation of identity.

11. VI. State oversight of denials: State review of denials and closures ensures appropriate application of state policy. The District of Columbia and Minnesota require that eligibility workers in field offices refer all cases they plan to close to a state-level central office for review. Virginia and Wyoming examine all denials and terminations made in field offices, and reopen closed cases for further investigation. Washington created a closure code specific to failure to submit identity or citizenship documentation to track the requirements impact.

12. What can advocates do? 1.Collect personal narratives. 2.Identify failures and trouble spots in state policy. 3.Make partnerships with other stakeholder groups. 4.Track enrollment data to identify trends. 5.Lobby state policymakers and Medicaid agency to adopt best practices.

13. Families USA resources Background information about DRA and citizenship documentation requirement online: http://www.familiesusa.org/issues/medicaid/m edicaid-alert-dra/ http://www.familiesusa.org/issues/medicaid/m edicaid-alert-dra/ Coming soon: Best practices issue brief. Families USA staff available to answer questions, discuss our findings, analyze state policy changes. Ella Hushagen: ehushagen@familiesusa.orgehushagen@familiesusa.org 202-628-3030