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Urgent: CMS Issues Guidance on Citizenship Documentation for Medicaid Beneficiaries and Applicants

The Deficit Reduction Act (DRA) was signed into law on February 8, 2006.  The bill includes new requirements for anyone currently on Medicaid or applying for Medicaid benefits. Starting July 1, 2006, anyone applying for or being recertified as Medicaid eligible will be required to document United States citizenship and identity.  Prior to the DRA, states could allow individuals to self-declare citizenship.  Now they will be required to show documentation.

States recertify individuals every 6-12 months, so all Medicaid beneficiaries will go through this requirement before July 2007.  All new applicants are subject to the requirement.

The requirements for aliens are unchanged by the DRA.  They will continue to be required to offer proof of immigration status under prior law.

On June 9, 2006, the Center for Medicare and Medicaid Services (CMS) issued a Dear State Medicaid Director letter to the states with guidance on implementation.  We now know more about what is required, but several key issues must be determined by the individual state. 

As advocates, it is very important that we understand these new requirements and communicate them to our members, fellow advocates and local mental health professionals.

As with many Medicaid guidelines, this letter is very complex.  CMS is clarifying the letter on calls and with other communications and these materials will be updated   as more information becomes available.  Please check the NAMI website at [link] for the latest information.  Also feel free to call or email us with questions, concerns or comments.  Contact information is provided at the end of this document.

Some Critical Information:

  • Once individuals meet the documentation requirements, it ought to remain in their record so they do not have to meet the requirements each time they are recertified. 
  • Medicaid beneficiaries should be given a reasonable opportunity to get their documents.  Generally, individuals may have up to 45 days.  People with disabilities, including those on SSI, may have up to 90 days to meet the new requirements.  
  • The guidance specifies that states can give more time to those already on Medicaid who are trying in good faith to get documents but cannot do so because the documents are not available and the state should assist those individuals in securing the needed documents.  However, it also states that new applicants may not get Medicaid until evidence of citizenship and identity have been provided.
  • CMS writes that states should assist applicants or recipients who are “homeless, an amnesia victim, mentally impaired, or physically incapacitated” who lacks someone who can act for the individual and who cannot provide evidence of citizenship or identity.
  • States can get 50% federal administrative match for any expenses they incur from the documentation requirements.  It appears that states may, as part of their assistance, help pay the costs to obtain citizenship or identity documents and get federal matching funds, but this is not required.
  • States can use data from the State Data Exchange (SDX) for SSI recipients to prove citizenship. It is unclear whether the data can also be used to establish identity.  The SDX is an automated data system in which the Social Security Administration shares selected data about SSI beneficiaries with state agencies.  States can also use vital statistics information from the state vital statistics agency to prove citizenship and an individual would have to establish their identity.   THESE ARE STATE CHOICES.   If your state chooses to use data matches, this would decrease the burden and expense for individuals.
  • CMS will be launching an outreach program including presentations to interested groups and educational tools.  A separate fact sheet states that these materials will include talking points, questions and answers, a sample press release, drop-in article and list of acceptable documents.

Acceptable Documents:

The letter sets forth four levels of acceptable documents to establish citizenship as well as a list of documents that can be used to prove identity.  If the individual provides documents from the first level, they don’t need to present anything else because these documents show both citizenship and identity.  If they cannot provide any of these documents, the state looks for a document in the second level and also must obtain a separate identity document.  If the individual cannot provide documents from that list, the state continues to the next level and then to the final level.  Identity documents are also needed to accompany third and fourth level citizenship documents.  For a complete list of the four levels of documents and documents that can prove identity please click here.

How Can People with Serious Mental Illness Satisfy the Requirements:

1.  Check to See if you have Necessary Documents on Hand:

A) Do you have a passport?  The guidance states that a current or expired passport meets the requirements as long as it was issued without limitation.  If you have a passport, you don’t need any other documents and you will satisfy the documentation requirement for both citizenship and identity.

B) If you don’t have a passport, do you have a birth certificate and some form of identification? You need BOTH a birth certificate and identification.  See the link above for the list of identity documents.  Some individuals with mental illness have obtained a birth certificate in order to apply for Social Security or transportation programs.  Check personal files and records and also check with case managers and other providers who may have such documents on record.  Copies or notarized copies are not sufficient.  You have to provide the originals or copies certified by the issuing agency.

C) Do you have any of the other documents listed in the second, third or fourth levels and an identity document? 
Click here for the list of documents.

2.   If you do not have these Documents:

  1. States have choices to make that could affect your need for documents.  For example, states can use data matches with other agencies.  So for example, states already receive the State Data Exchange (SDX), which has information on citizenship for SSI recipients.  The state can choose to use this information to satisfy the citizenship requirement. It is unclear whether it can satisfy identity also.  The state can also choose to use vital records information by matching with State vital statistics agencies and an individual would only have to prove identity, not citizenship.  But THESE ARE STATE CHOICES so you will have to find out what is the process in your state.
  2. If your state has not determined its process yet or you want to be sure to meet the requirements, you can order your birth certificate and get state identification. You can go online and click on the state of birth for information on how to order one.  There is usually a cost associated with obtaining a birth certificate - $10-20 in most states.  Obtaining birth certificates can take several weeks so individuals are encouraged to start the process early.   The guidance states that all Medicaid beneficiaries may have up to 45 days and people who are on Medicaid because of their mental illness or other disability may have up to 90 days to produce their documents, and could have longer if they are trying to get them but they are not available.  The guidance also says, however, that applicants will not be eligible for Medicaid until they produce the documents, so it is important to start the process quickly if you are applying for Medicaid.   The Deficit Reduction Act and the guidance do not specify who should pay the cost of the documents.  The guidance says that the state should help those with mental impairments, so ask if this help can include paying or waiving the fee. 
  3. A birth certificate, however, is not sufficient.  An individual must also have a form of identification such as a driver’s license or a state-issued identification card.  Click here for a list of identity documents.  For a driver’s license or a state-issued identification card, check with your state.  Most commonly, these are issued by the department of motor vehicles, but each state is different.   Each state has its own requirements.  There is a cost associated with these cards so ask if these fees can be paid by the state or waived. 
  4. If you are a Native American, there are several documents you can use.  See further details.

Advocacy Suggestions: Working with your State NAMI and Affiliates to affect state policy:

Now the advocacy moves to the state, where your state Medicaid agency or the agency that determines eligibility for Medicaid will be developing procedures that will guide local implementation.

Advocates should work with their state NAMI leaders and affiliates on a coordinated strategy to try to get meetings with key state officials.  The goal is to get information and to press for procedures that are most beneficial to people with serious mental illness.

Here are some advocacy steps to address this critical issue.  As an important part of each of these strategies, ask your state to go on record sooner rather than later on how they are handling this requirement so that applicants and recipients can have as much time as possible to prepare for this change in policy.

  1. Get information from the agency that will be making the rules in your state.  In most states, that will be the state Medicaid agency, but some states use other agencies to process eligibility for Medicaid.  Ask to meet with them so you can determine what the process will be for your state. 

    Some states, such as Montana, New York, New Hampshire and Georgia already have documentation requirements.  The CMS letter states that New York and New Hampshire’s published guidelines are similar to the CMS letter.  Other states don’t have any documentation requirements and are starting from scratch.
  2. Urge your state agency to use data matches whenever possible. For individuals on SSI, CMS has indicated that states can use the State Data Exchange (SDX) to satisfy the requirement for citizenship and possibly identity so individuals on SSI would not have to provide any documents.  As noted above, the SDX is an automated data system in which the Social Security Administration (SSA) periodically shares selected data about SSI beneficiaries with state agencies.  The SDX includes SSA data about citizenship status for those on SSI.  States can also use information from the state vital statistics agency to establish citizenship and the individual will only need to show identity.   These are CHOICES, so urge your state to make the right choice and take the burden and cost away from the individual whenever possible.  The data matches will also make it easier for applicants to quickly get on Medicaid.

    Note:  Data matches are not always reliable because of alternative spelling of names, typographical errors, and out of date records.  As a result, if data does not match, an individual should be given an opportunity to provide other documentation of citizenship.
  3. Advocate with your state to get the most help for individuals with mental illness, including assistance with the costs for any documents that are needed.  The guidelines instruct states to assist individuals with mental illness to document U.S. citizenship and identity.  Ask them how they will do this Urge them to pay the cost of any documents.  According to CMS, states can get 50% reimbursement from the federal government for any of the expenses associated with the documentation requirement.   Explain that individuals with mental illness have very little disposable income and are already stretched by necessities such as rent, food, co-pays, etc.  For example, a report from the Technical Assistance Collaborative, Priced Out in 2004, shows that 96% of an individual’s SSI check would be needed to pay the average rental on a studio or efficiency apartment in this country.
  4. Offer to partner with the agency to do outreach to NAMI members and advocate for the state to do extensive outreach and education on the new requirements.  Urge the agency to conduct specific outreach to homeless individuals, those coming out of jails and prisons, and other hard to reach individuals.   Urge them to produce some simple outreach materials that NAMI and others can distribute. Offer to review the materials and provide suggestions.
  5. Get the word out about these new requirements.  Talk with peer and family support groups, clubhouses, conferences, churches, and other social organizations. Post information on your website or through your newsletter. Make sure that providers in your area are aware of these new provisions, including case managers, community mental health centers, mental health agencies, public health clinics, and others. 
  6. Document any problems with the implementation of the new law.  If individuals with serious mental illnesses are unable to comply with these requirements and are denied treatment, record their experience and the consequences.  Share these stories with NAMI’s national office, the media and state and federal policymakers.
  7. If your state agency is slow to respond to requests for clarification and/or fails to take steps to ease the burden on recipients or applicants, work with your state NAMI organization to consider alternative strategies.  Consider approaching state legislators with a strong interest in Medicaid or mental health and/or the Governor’s office.  If your state legislature is still in session, state legislation or a legislative resolution could provide leverage.
  8. Work with other interested groups to advocate, publicize, and monitor implementation of these new documentation requirements.  Disability advocacy organizations, multicultural coalitions, and other organizations representing low income individuals may also be working on these issues. 
  9. Provide public comment before a state Medicaid oversight body if your state has created a board or commission for that purpose.  Many states have public bodies responsible for oversight of state Medicaid policy.  Attend one of their regularly scheduled meetings and urge them to minimize the burden and provide extensive assistance and outreach to individuals with serious mental illness.   

Helpful Links:

For the statute, a fact sheet and the Dear State Medicaid Director Letter click here.

For Questions and Further Assistance:

Please call Mary Giliberti at NAMI National: (703) 524-7600 x7948 or write


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