June 20, 2006
USING INFORMATION TECHNOLOGY TO DOCUMENT CITIZENSHIP IN MEDICAID
By
Leighton Ku
HHS Secretary Michael Leavitt has stated that
federal programs like Medicaid should be leaders in the adoption of information
technology to modernize health care systems.[1]
On June 9, the Centers for Medicare and Medicaid Services (CMS) issued federal
guidance with directions to states on how to implement a new requirement that
American citizens document their citizenship when applying for Medicaid or
renewing their coverage.[2]
The guidance appears mired in an old-fashioned paperwork-intensive system, and
as a result, is virtually certain to create unnecessary barriers for substantial
numbers of beneficiaries and administrators. CMS should consider how to
encourage the use of information technology to meet the new requirement more
effectively and efficiently, and thereby to prevent U.S. citizens who meet all
of the Medicaid eligibility criteria from losing their Medicaid coverage and
becoming uninsured as a result of paperwork problems.
The new HHS guidance implements a provision of
the Deficit Reduction Act enacted earlier this year that requires U.S. citizens
participating in Medicaid to prove their citizenship.[3]
This provision will apply, as of July 1, 2006, to each of the more than 50
million U.S. citizens who receive health care coverage through Medicaid, as well
as to all citizens who apply for Medicaid in the future. The Deficit Reduction
Act specifies that U.S. passports and birth certificates meet the requirements.
It gives HHS the option to authorize additional documents, but does not specify
whether paper or electronic documents meet the requirements, leaving that to HHS
to determine.
The Reliance on a Complex Paperwork System
The new CMS guidance establishes a complex
four-tier hierarchy of paper documents as the primary ways to satisfy the new
requirements. U.S. passports are in the first tier. If they are not available,
birth certificates and selected federal documents in the second tier may be
used, and so on. The third and fourth tiers include other paper documents, such
as hospital, insurance and nursing home records and affidavits signed by at
least two other citizens who have personal knowledge of an individual’s birth in
the United States. The use of documents in the second, third or fourth tiers
must be accompanied by documents that prove identity, such as driver’s licenses.
The June 9th guidance largely ignores the use of
electronic records that already are available to the federal and state
governments and could be used to readily determine whether someone is a
citizen. For example, many states have computerized vital records systems that
contain data on all birth certificates issued in that state and that could be
used to swiftly determine whether a Medicaid beneficiary or applicant was born
in that state and is therefore a native-born citizen. Using data systems like
these can be much speedier and far less burdensome than requiring each of the
more than 50 million low-income citizens on Medicaid, many of whom are elderly
or have severe disabilities, to locate or obtain an original or certified birth
certificate, passport, or other permissible document and bring or mail that
document to the eligibility office. It also could lessen the need for state
Medicaid eligibility workers to review huge quantities of paper documents, copy
and store those documents in paper files, and return or mail the original
documents back to the individuals.
In many states, the use of electronic records
already is facilitating the use of mail-in, telephone or internet-based
applications for Medicaid, which many agencies are using (or developing) to
reduce the reliance on face-to-face interviews. Using electronic records for
citizenship would supplement this approach. It could sharply reduce the number
of paper documents that otherwise will have to be submitted, reviewed and stored
and make the overall process faster and more efficient, while reducing the
number of poor beneficiaries who “fall through the cracks” and are cut off
Medicaid as a result of the new requirement.
Yet the June 9th CMS guidance appears to block
such an approach. The guidance suggests that automated records may not be used
until after “an applicant or recipient in good faith tries to present
documentation, but is unable to do so because the documents are not available
[within a time period of 45 to 90 days].”[4]
The guidance also notes that CMS is working with other federal agencies to
develop new automated data systems to check citizenship, but these would
primarily be used to further verify third- and fourth-tier paper documents (such
as hospital records or personal affidavits) that had already been submitted.
Rather than encouraging the use of information
technology, CMS appears to be discouraging it. Prior to issuance of the
guidance, a number of states had been planning to use electronic records and
data matching to document citizenship for as many people as possible. The new
CMS guidance appears to be having a chilling effect on these plans. It also may
have harmful repercussions for other components of program administration.
The State of Washington, for example, has a
paperless document management system for all of its Medicaid records; when paper
records are provided, they are scanned and stored electronically. The new CMS
guidance threatens this system by appearing to mandate that records be stored in
paper files.
Fostering the Use of Information Technology
CMS ought to consider opportunities to improve
its policies and to facilitate the use of information technology. The following
are some of the steps that CMS could take.
- Encourage the use of automated systems to
determine if Medicaid beneficiaries or applicants are U.S. citizens. Rather
than suggesting that data matches are a last resort, CMS should make them
equivalent to paper records as an option. In addition, when electronic records
are used, the submission of unnecessary pieces of paper and wasteful retention
of paper records should not be required.
- Let states use electronic claims data to document
that Medicaid has paid for a baby’s birth in a U.S. hospital. Many babies are
entitled to automatic enrollment in Medicaid because their mothers were Medicaid
beneficiaries when they delivered. There are sometimes delays, however, in the
issuance of birth certificates for these babies. The Medicaid agency knows that
these babies are citizens because the Medicaid claims data show they were born
in U.S. hospitals. These data should be sufficient to document these babies’
citizenship, and thereby to expedite their Medicaid coverage. It makes little
sense to insist that parents first try to secure and submit passports or birth
certificates for these babies.
- Use Supplemental Security Income program data
more effectively to check the citizenship of SSI beneficiaries. As CMS has
noted, the Social Security Administration’s State Data Exchange (SDX) file
contains information about the citizenship of SSI beneficiaries.[5]
While a draft version of the CMS guidance required that states check the SDX
system to help document Medicaid citizenship, the final guidance appears to
suggest that this, too, can be used only as a last-resort option.
- Use other federal automated data to determine
citizenship or U.S. birth. The federal government already has data about
citizenship for a large share of Americans, as well as data about the place of
birth for virtually all people with Social Security numbers (SSNs). These data
are part of the Social Security Administration’s NUMIDENT data system, which
contains information about all people who have applied for Social Security
numbers. NUMIDENT includes the place of birth for all those with SSNs,
including those who applied for SSNs, as well as data about citizenship status
for all those who have applied for SSNs since 1972.
SSNs are required for Medicaid beneficiaries.
This means that Medicaid and NUMIDENT data could be matched to determine whether
a Medicaid beneficiary was born in the United States. The match could yield
citizenship data for a substantial share of Medicaid beneficiaries.
In addition, CMS possesses data in automated form
for all elderly and disabled beneficiaries who are dually eligible for Medicare
and Medicaid.[6]
If NUMIDENT data were made available from SSA, CMS could itself match these
Medicaid beneficiaries with SSA records to determine who is U.S.-born. The
Social Security Administration, however, currently does not make citizenship or
place of birth data available for purposes like this to CMS or the states.
Federal agencies should be discussing how to modify this SSA procedure so these
data can be used to help document citizenship for Medicaid. It is unclear
whether this is occurring.
- Permit other approaches or data bases that meet
these needs. In our information-rich nation, other reliable public or private
data bases or information technology may be available or could be developed that
would help meet this purpose. Federal rules should not preclude the potential
for innovative alternatives that states may identify to meet these needs more
efficiently and effectively.
While information technology can make the
determination of citizenship simpler and more efficient, it is not a panacea.
In some cases, automated matches will not identify a person’s citizenship
because a data base is incomplete (e.g., a vital records system may have
information only about births in one state) or out-of-date (e.g., an immigrant
may have become a naturalized citizen since the records were last updated). In
addition, matches sometimes fail for technical reasons (e.g., transposed letters
or numbers, typos, etc.).[7]
In cases when citizenship cannot be ascertained from electronic records,
individuals always should have the opportunity to submit alternative
documentation to prove their citizenship. It also will be important to avoid
situations in which data errors or omissions lead to denial of, or delay in,
providing health care coverage to an individual who meets all of the eligibility
criteria for it.
CMS has stated that its June 9th guidance will
soon be followed by interim final regulations with an opportunity for comments.
But CMS need not wait until the comment period is over and final regulations are
issued, which is likely to be many months (or years) from now. Even before
issuing the interim regulations, CMS can consider how to foster the use of
information technology to document citizenship in Medicaid, in order to lessen
the reliance on paper documents and reduce the serious burdens that the June 9
guidance will place on many low-income Americans (and program administrators as
well) when the requirement to prove citizenship takes effect on July 1.
End Notes:
[1] “Secretary Leavitt’s 500 Day Plan.”
www.hhs.gov/500DayPlan/500dayplan.html#HealthCare.
[2]
CMS State Medicaid Director letter, dated June 9, 2006.
www.cms.hhs.gov/smdl/downloads/SMD06012.pdf.
[3]
For more discussion of the June 9 guidance, see Judith Solomon and Andy
Schneider, “HHS Guidance Will Exacerbate Problems Caused by New Medicaid
Documentation Provision,” Center on Budget and Policy Priorities, June 16,
2006. For discussion of the legislation and potential impact, see “The New
Medicaid Citizenship Documentation Requirement: A Brief Overview,” Center on
Budget and Policy Priorities, April 20, 2006.
[4]
This is what the written guidance says. In a nationwide telephone
conference call on June 12, a senior CMS official suggested that states could
use data matching as a primary option. The discrepancy between the written
and oral guidance indicates there is some apparent ambiguity that needs to be
clearly resolved in written form.
[5]
SDX is an extract of the Social Security Administration’s SSI files which is
periodically shared with state agencies.
[6]
CMS collects these data from states to administer the Medicare prescription drug
benefit for dual eligibles.
[7]
More sophisticated data matching systems use algorithms that can account for
some of these errors in a variety of ways. |