In June of 2007, the California Department of Health Care Services (DHCS) released guidelines for the implementation of citizenship and identity verification requirements in Medi-Cal. These new requirements, imposed under the Federal Deficit Reduction Act of 2005, require that all beneficiaries and applicants of Medi-Cal verify their US citizenship and identity in order to apply for or renew Medi-Cal benefits. DHCS expects these requirements will be enforced in the fall.

Key Features of the New Medi-Cal Law

• Citizenship verification is not required for individuals who declare he/she is an immigrant.
• Only individuals who claim US citizenship or US national status must be verified.
• Individuals must provide documentation of two things:  1) Proof of citizenship and 2) Proof of identity.
• Citizenship and identity documentation is a one-time activity.  Once documentation is obtained, a beneficiary never has to provide it again.
• SSI, Medicare and CalWORKS recipients do not have to prove citizenship and identity.
• Individuals who do not provide the necessary documents after the time limits have expired will only received restricted Medi-Cal benefits.
• The law outlines the specific documents that can be used to verify citizenship and identity.
• Federally qualified health centers can review original citizenship and identification documents on the county’s behalf as part of “initial processing.” 

New Applicants vs. Ongoing Beneficiaries

New applicants are treated differently than ongoing beneficiaries:

• A new applicant who meets the other requirements for Medi-Cal, is not eligible for the program until proof of citizenship and identify is obtained.
• Ongoing beneficiaries, who must prove citizenship and identity, will remain eligible if they are making a good faith effort to provide documents.
• Individuals who are establishing presumptive eligibility or accelerated enrollment are not subject to the new verification rules.  The requirements apply, however, when the individual’s ongoing Medi-Cal eligibility is determined.

State and Local Implementation

DHCS is electronically cross-referencing state birth records and Medi-Cal records to identify applicants and beneficiaries born in California. If a matching birth record is found, DHCS will inform applicants and beneficiaries that they have met the citizenship documentation requirement but must still provide evidence of identity.

California counties will mainly be responsible for verifying citizenship and identity when applicants apply for Medi-Cal and current beneficiaries renew their benefits, as well as providing assistance in obtaining the necessary documents.

Children and the New Medi-Cal Rules

Citizenship and identity verification for children is dependent on whether or not the child was born in California and the age of the child. If DHCA finds a birth records for a child born in California, then no additional documents to establish citizenship are needed. Otherwise, children have to still verify their citizenship in the same manner that adults do. For children under age 16, if the Medi-Cal application or the Medi-Cal/Healthy Families joint application with the child’s date and place of birth is filled out and signed, under penalty of perjury, by a parent or guardian proof of identity is not required.  (This signed application is proof of the child’s identity). For children over age 16, proof of identity for the child is required in the same manner required by adults.

For children who are not U.S. citizens, the Medi-Cal application process has not changed.

Adverse Effects

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CPCA’s Federal Advocacy Efforts

CPCA is joining with other organizations to urge, through reauthorization of the State Children’s Health Improvement Act, Congress to support a provision that gives states the option of verifying citizenship and identity. Currently, Governor Schwarzenegger and both Senators Boxer and Feinstein are supporters of this measure.

For more information, please contact Jamila Iris Edwards at jedwards@cpca.org or (916) 440-8170 x. 234.

What Clinics Can Do

• If you are an FQHC, verify documents at your clinics.

DHCS allows FQHCs to verify citizenship and identity documents. Providing this verification will assist applicants and beneficiaries in overcoming the obstacles of obtaining documentation and traveling to county offices to get documents reviewed.

• Provide certified copies of medical records as needed.

The federal guidelines allow medical records (except immunization records) to be used as a form of citizenship documentation. Let patients know this is an option and let staff know to provide these records as requested in a timely fashion.

• Get involved in your county’s implementation process.

California counties are responsible for primary document verification and are currently being trained in the process. Contact your county Medi-Cal office to find out how the requirements will be implemented in your county to provide input and advocate for patients.

• Encourage patients to obtain documents in anticipation of enforcement.

Even though the requirements will not be enforced until fall of 2007, please let patients know as soon as possible that they should begin the process of obtaining the required documents.

• Support DHS outreach by posting materials as soon as possible.

DHCS has a variety of materials available on their website which provide information about the requirements. Display these materials in your clinics as a way to inform patients.

• Document effects in your clinic.

As a member of the Coalition for Kids and Families (CKF), a collaborative of health advocates, healthcare providers, professional health associations, representatives from the education community and other key agencies dedicated to increasing health coverage for low income children and families, CPCA will be joining in CKF’s efforts in tracking the effects of the Deficit Reduction Act. Community Health Councils/CKF in collaboration with the 100% Campaign has developed a one-page tracking tool that organizations can utilize to gauge the experiences of new and current Medi-Cal consumers at the community level.  The intent is to share what we learn from our community partners at the local level with our coalitions, the state, and our elected officials to demonstrate the impact the new policy has on citizens’ eligibility determinations in California.  CKF intends to pilot test the tool with a couple of counties to ensure that they are asking the right questions to identity barriers that applicants may be experiencing when trying to obtain documents. Clinics are encouraged to utilize the tool once it has been finalized.

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• CPCA Web-Based Trainings on Citizenship Verification ( June 28, 2007 and July 10, 2007)
• Guide to Citizenship Verification
• Medi-Cal's Website on the Federal Deficit Reduction Act
• Centers for Medicare and Medicaid Services’ website on the Deficit Reduction Act
• George Washington University Study on the Effects of the Citizenship Verification Requirements in Health Centers
• Center for Budget and Policy Priorities Report on Effects of Citizenship Verification on Medicaid Enrollment
• GAO Report on the Effects of Citizenship Documentation Requirements

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• Update on Citizenship Verification (2/11/08)

The week of January 28, 2008, notices from the Department of Health Care Services were sent to Medi-Cal beneficiaries with annual redetermination dates in March, April and May, informing them of the new requirement to provide citizenship and identity documentation during their Medi-Cal renewal. For those Medi-Cal beneficiaries who are not exempt from the requirements, DHCS has also already sent them a notice informing them whether or not a birth record match was found for them. These notices will continue to be sent out on a quarterly basis.

Actual implementation of the requirements still varies by county. Originally most counties planned on delaying implementation until DHCS responded to questions from counties and updated the Medi-Cal Eligibility Data System (MEDS). However, most counties will be going ahead with full implementation very soon. Lake, Sutter, Mendocino and Nevada are among the counties that we have learned are already starting verification, while Riverside and Santa Clara are in the process of beginning and San Diego and Fresno plan on starting soon. It is important to contact your local county and find out their timeline of beginning implementation so that you can help any clients with questions.

DHCS is also still currently considering allowing Certified Applicant Assistants (CAAs) to perform the document verification. As it remains, FQHCs and Disproportionate Share Hospitals are the only non-county groups allowed to perform the verification.

Again, please keep CPCA informed if you plan on performing the verification, if you need more information on it, or if you would like further training. Although FQHCs are allowed to perform the documentation, DHCS will not be reimbursing clinics or providing any additional training on the process. Jamila Iris Edwards, at jedwards@cpca.org or (916) 440-8170, is the contact at CPCA regarding citizenship verification related issues.

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