September 1, 2006
DOCUMENTING CITIZENSHIP AND IDENTITY USING DATA MATCHES
A Promising Strategy for State Medicaid Programs
By Leighton Ku, Donna Cohen Ross and Matt Broaddus
Under the Deficit Reduction Act of 2005 (DRA),
U.S. citizens must document their citizenship and identity when applying for
Medicaid or renewing their coverage. The new requirement, which took effect on
July 1, could jeopardize the health coverage of substantial numbers of eligible
citizens who are unable to secure the required documentation.
 The significant challenges that many
citizens — primarily children, parents, pregnant women and people with
disabilities — will face as they attempt to obtain the required documents could
result in their health coverage being delayed or denied. That, in turn, could
deprive them of preventive and prenatal care and other necessary medical
The requirement also creates new administrative
burdens for states, since it applies to all current Medicaid beneficiaries and
all applicants except those who participate in both Medicaid and Medicare
(so-called “dual eligibles”) or are enrolled in Medicaid as a result of
receiving Supplemental Security Income (SSI) benefits. Much of this burden will
be felt over the course of the coming year, during which about 38 million
U.S.-born adults and children currently enrolled in Medicaid will be subject to
the new requirement when they seek to renew their coverage. In addition, about
10 million otherwise eligible U.S. citizens can be expected to apply for
Medicaid each year. Applicants unable to produce the documents will be denied
Implementing the new requirement thus will pose
daunting challenges for states. States can, however, substantially reduce the
burdens on themselves, and on applicants and beneficiaries as well, by adopting
an option made available in the interim final regulation that the Centers for
Medicare and Medicaid Services (CMS) issued on July 12.
This option allows states to obtain evidence of a person’s U.S. citizenship and
identity by conducting electronic cross-matches with existing databases, such as
vital records, Social Security, the Food Stamp Program, and the state motor
By adopting this option, states can free many
people from the need to obtain and submit the required documents. Adopting the
option also will minimize the increased costs that state and local agencies will
face in conducting eligibility determinations. For example, the option can help
states retain mail-in enrollment and renewal systems and thereby lessen or avoid
the need to hire additional workers to handle an influx of in-person
applications. (If the option is not adopted and many applicants and
beneficiaries are unwilling to mail original copies of important documents and
risk having them lost, mail-in enrollment could deteriorate.) In addition, by
enabling eligible U.S. citizens to retain or promptly gain Medicaid coverage,
data matching can help to ensure that health care providers receive Medicaid
payments for services rendered.
This paper describes how some states are
implementing or planning to implement the electronic data match option. It also
explains the technological and logistical challenges that some states may
encounter as they explore the possibility of conducting such matches and some
possible solutions. Not all states have the capacity to fully avail themselves
of this option, however.
Cross-Matching with Vital Records Could Document
Most Individuals’ Citizenship
Cross-matching with state vital records databases
holds significant promise as a method to document citizenship for U.S.-born
individuals. The interim final regulations allow states to use a successful
match with vital statistics data as documentation in lieu of an individual’s
having to submit an original or certified birth certificate.
Most state’s have computerized vital records databases that contain records of
certified births in the state, although it should be noted that state agencies
cannot readily check automated records for state residents who were born in
New analyses of Census data by the Center on
Budget and Policy Priorities indicate that vital records matches can document
the citizenship of the great majority of U.S.-born citizens. We examined data
from the Census Bureau’s 2004 American Community Survey to determine the
percentage of U.S.-born non-disabled individuals under age 65 with low incomes
(below 150 percent of the poverty line) who live in the state where they were
- As Table 1
shows, 86 percent of low-income U.S.-born children and 67 percent of
low-income U.S.-born adults live in the state where they were born and
therefore could be identified through a match with state vital records.
- These percentages vary widely across the
states, but in every state, the great majority of native-born children and a
substantial fraction of U.S.-born adults could be identified through a vital
People for Whom State Vital Records Matches
Percentage of Low-income U.S.-Born Children and Adults Who Live
in the State in Which They Were Born
Children Under 18
18 to 64
Children Under 18
18 to 64
District of Columbia
Notes: CBPP tabulations of the 2004 American
Community Survey. Based on U.S.-born persons with incomes below 150
percent of the poverty line. Excludes those over the age of five who are
After accounting for the exemption from the new
documentation requirement for Medicaid beneficiaries who also are enrolled in
Medicare or SSI, we estimate that about 38 million U.S.-born individuals now
enrolled in Medicaid will be subject to the new requirements when they seek to
renew their coverage.
An additional 10 million American citizens are eligible apply for Medicaid each
year; they, too, will be subject to the new requirements.
Administrative data indicate that more than half of the women enrolled because
they have low incomes and are pregnant enter as new applicants during a year, as
do one-quarter of children. As a result, the provisions that bar new applicants
from receiving coverage until documentation is submitted could lead to delays in
obtaining prenatal care for significant numbers of pregnant women and preventive
and acute care for many children unless states institute systems to match
Cross-Matching With Other Databases Could
Document Citizens’ Identities
Most Medicaid applicants and beneficiaries will
be required to document their identity as well as their citizenship. Although a
passport satisfies both requirements, a birth certificate counts only as
evidence of citizenship, so individuals who present a birth certificate or have
a vital records data match also must produce a separate document proving their
This means that if a state opts to conduct a vital records data match but does
not also conduct matches to obtain identity documents, individuals will still
have to prove their identity by visiting the Medicaid office to present a
driver’s license or other form of proof. That would compromise a state’s
mail-in application and renewal procedures. Fortunately, the interim final
regulations also allow states to document identity through cross-matches, using
state or federal databases such as those used in the Food Stamp Program, the
child support system, and motor vehicles departments.
Stamp or TANF data may be particularly attractive, since Medicaid eligibility
data systems often already are linked to eligibility data systems for state Food
Stamp and TANF programs. Food Stamp regulations already require states to
verify the identity of heads of household, and
states likely will already have gathered the identity documents of many
low-income individuals in the process of documenting these individuals’ identity
or other information (such as age or residency) for Food Stamps or TANF. The
many Medicaid beneficiaries who are currently enrolled or previously have been
enrolled in these programs could have their identities readily documented in
this manner. In some cases, records from other programs such WIC or child
support also are available and could be used in a similar fashion.
Some Medicaid eligibility agencies also may be
able to obtain online access to data on driver’s licenses or state-issued
identification cards from state motor vehicle departments. If so, this could
provide proof of identity for a majority of adult Medicaid beneficiaries, who
are likely to have either a driver’s license or state-issued identification
How Some States Are Implementing Data Matches to
Document Citizenship and Identity
States that are conducting data matches or plan
to do so are employing a variety of approaches. The approaches used to match
data for beneficiaries seeking to retain their Medicaid coverage may differ in
some respects from the methods used for new Medicaid applicants. State agencies
that determine Medicaid eligibility can usually search their agency records to
obtain identity documentation submitted for other benefit programs, but they
must search records outside their own agency to document citizenship. Described
below are the approaches being used by four states: Washington, Louisiana,
Iowa, and Utah.
focus on matching current beneficiaries. Washington State plans to conduct a
large, batch-style vital records match of all Medicaid beneficiaries who are
subject to the documentation requirement. In a batch-style match, data about
Medicaid beneficiaries are matched against vital records data for thousands of
records at a time rather than on a case-by-case basis.
In Washington State, the state Medicaid office
will match hundreds of thousands of computerized Medicaid records against the
vital records database. The state anticipates that the system will be very
efficient, with a single programmer able to check about 35,000 records per day.
Ten new staff will be on hand to search the vital records system further in
cases where initial attempts at matching are unsuccessful. The state decided to
conduct the matches centrally in order to avoid burdening eligibility workers
with the job of doing the “detective work” necessary when a match is not readily
A positive match (i.e., proof that a Medicaid
beneficiary was born in Washington State) will be recorded in the computerized
Medicaid eligibility files, which are accessible by local eligibility offices.
If a beneficiary’s citizenship cannot be ascertained through the vital records
match, local eligibility staff will ask the beneficiary to submit paper
documentation. In the event that beneficiaries are unable to submit such
documentation, a centralized staff unit will attempt to obtain appropriate
documentation for the person.
Washington also is developing approaches to
conduct data matches for new applicants. State eligibility staff currently have
the ability to do on-line “look-ups” of new applicants’ vital records, but this
capability is somewhat more labor intensive as it requires eligibility staff to
log in to a separate system. The state is trying to determine if it is possible
to make this capability easier.
Louisiana: conducting “real-time” matches
for applicants and beneficiaries. In Louisiana, local eligibility staff will
conduct “real-time” online matches with vital records data as part of the normal
process of determining Medicaid eligibility for new applicants and beneficiaries
seeking to renew their coverage. “Real-time” matches allow eligibility workers
to obtain the most up-to-date information available at any given moment.
Since Louisiana requires child applicants for
Medicaid to provide proof of age, the state already has systems in place to
permit a limited number of eligibility workers to look up vital records data on
their computers and determine immediately whether there is a birth certificate
in the state’s system. The match takes less than a minute. When a match is
successful, the caseworker prints the screen and scans it into the electronic
case record. To implement the new Medicaid documentation requirement, the state
has expanded the authorization for access to the online vital records system to
more than 1,000 Medicaid eligibility staff statewide.
One limitation of Louisiana’s system is that
records for people born before 1984 are frequently unavailable since most older
birth records have not been entered into the automated system.
Individuals for whom a match cannot be found will be asked to submit paper
documentation. Louisiana also is checking available databases (including Food
Stamps, TANF, Department of Labor, Social Security databases, like SDX or BENDEX,
and WIC) to obtain proof of applicants’ and beneficiaries’ identities.
When proof of citizenship and identity has been
obtained and scanned into the case record, the information is added to the
Medicaid “person record,” along with a notation explaining how the information
was verified. The state plans to keep the “person record” permanently so
individuals who leave Medicaid and later return to the program do not have to
re-supply citizenship and identity documentation.
Iowa: using a web-based request system. The
Iowa Medicaid agency is very interested in conducting vital records data
matching, but technical problems prevent the Medicaid staff from directly
accessing the state’s vital records systems. To surmount this obstacle, the
vital records and Medicaid agencies have developed a web-based system that
allows Medicaid eligibility workers to request birth certificates on behalf of
an applicant or current beneficiary.
The process works as follows. First, the
eligibility worker enters the client’s Medicaid number into a web-based system
designed for this purpose. The Medicaid eligibility system calls up information
it has for that individual that could help in securing a vital records match,
such as name, date of birth, and gender. (The eligibility worker can contact
the client for additional information that could aid in finding a match — such
as first, middle, and last name, county of birth, or mother’s maiden name — and
then enter this information into the database.) The eligibility worker also
indicates whether the request is for a new applicant or a current beneficiary.
Because the CMS regulations require delaying coverage of new applicants until
documentation is found, new applications receive priority.
Each night the system delivers a batch of
requests to the vital records department, which looks up each request
individually. When a match is found, vital records staff print a confirmation
that the birth certificate is on file; this information is then provided to the
Medicaid eligibility worker and becomes part of the person’s case record. If
the vital records worker finds a possible (as opposed to a definite) match, he
or she asks the Medicaid eligibility worker to get more information from the
client so the match can be attempted again. As of this writing, Iowa was field
testing this data-matching system; the time and effort involved in executing the
matches are not yet known.
Utah: checking multiple databases using a single
system. Established in 2004 to help reduce the state’s food stamp error rate,
Utah’s “eFind” system has significantly improved the ease and efficiency with
which caseworkers can search multiple databases to document individuals’
eligibility for a variety of public benefit programs. Previously, an
eligibility worker had to log in to each separate database to obtain
information. Now, some 18 sources of information, including databases and data
warehouse files for Social Security, alien registration, motor vehicles, food
stamps, TANF, and vital statistics, can be accessed through one system. The
time needed to conduct a full search for information has been cut from 17
minutes to three.
Another advantage of eFind is that all
caseworkers have access to it. Previously, only one or two caseworkers per
eligibility team were authorized to use the vital statistics software. Now that
birth records are contained in eFind, all caseworkers have access, and the vital
records agency has been freed from the administrative tasks associated with
authorizing individual caseworkers to use the system.
Utah is using eFind to implement the new Medicaid
citizenship documentation requirement. After a caseworker indicates that a
birth records search is desired for a given person, a check mark appears on the
screen to indicate if a match exists. If no check mark appears, the caseworker
can enter the birth records system to add information (such as mother’s maiden
name) to attempt to secure a match. If a match is found, the caseworker prints
out the screen and places it in the Medicaid case file.
Utah also has a separate records imaging system
that scans and stores all documents submitted to substantiate a person’s
eligibility for public benefits, including documents to prove income,
immigration status, U.S. citizenship, and identity. The Departments of
Workforce Services and of Health — the two agencies that determine Medicaid
eligibility — are using this system to help Medicaid applicants and
beneficiaries comply with the requirement to prove identity. For example, if a
food stamp recipient applies for Medicaid, the caseworker searches the records
imaging system to ascertain whether an image of the person’s driver’s license
(or other identity document) is on file, in which case the individual does not
need to produce that document a second time. The Department of Workforce
Services is discussing including driver’s licenses in eFind so that system could
be used to help document the identity of Medicaid applicants and beneficiaries,
as well as their citizenship.
Addressing Technical and Logistical Challenges
States face a number of technical and logistical
issues as they prepare to conduct data matches with vital records and other
databases. Below are suggestions for dealing with some of the most common
- Reduce administrative burden through
interagency collaboration. The new Medicaid documentation requirement results
in additional workload for both Medicaid and vital records agencies. This
workload can be reduced through collaboration. While vital records offices
benefit by collecting fees from individuals requesting birth certificates, few
if any are equipped to handle the expected influx of requests by Medicaid
applicants and beneficiaries. A strong case thus can be made that both the
Medicaid agency and the vital records agency will benefit from the
cross-matching of records.
State Medicaid agencies can help pay the costs
associated with cross-matching, either by paying a user fee for each vital
record match or by covering the cost of the additional state staff involved in
processing requests for documentation. These costs are eligible for
reimbursement by the federal government at the Medicaid administrative matching
rate of 50 percent.
technical experts within government agencies or from outside organizations.
Some states may have difficulty identifying technical staff who have the
knowledge and skills necessary to set up a system for effective data
matching. Computer and programming staff are often in short supply.
Sometimes, however, researchers from universities or health-related
organizations have experience matching Medicaid and vital records data.
For example, some researchers have developed this
area of knowledge in carrying out research on birth outcomes as part of
evaluations they are conducting of maternal and child health programs. Medicaid
and other human service agencies also typically conduct other automated
matching, such as matches with wage data from the Department of Labor and
matches with immigrant data from the Department of Homeland Security’s
Systematic Alien Verification of Entitlements (SAVE) database. These staff or
private contractors may be able to help with matching.
- Ensure that sufficient data are collected to
execute efficient matches. In general, Medicaid applications solicit
applicants’ names, dates of birth, and Social Security numbers (SSNs). All of
these information elements can be used to match against vital records data.
Additional information is sometimes needed, however, to distinguish records
that are nearly identical or when the usual basic information is not in the
system. If, for example, a child has not yet been named when the birth
certificate is recorded, additional information (such as the mother’s name and
the child’s gender, birth date and birth place) can help complete the match.
A number of states have revised or are in the process of revising their
Medicaid applications or related forms to ensure that they collect critical
information needed to conduct a successful match.
Similarly, finding birth records for adult women
can sometimes be a problem because women’s names often change due to marriage.
Several states are beginning to collect mothers’ maiden names on Medicaid
applications to improve matching. Washington State found it could sometimes
infer a mother’s maiden name from her child’s birth certificate, and then
conduct a search for the mother’s birth certificate using her maiden name.
- Use multiple approaches to increase successful
data matches. Using multiple approaches to matching can increase the number
of cases matched. For example, a child health research project conducted by
Connecticut Voices for Children needed to match birth records and Medicaid
enrollment data. More than 9,000 records were matched using a mother’s SSN
and the child’s date of birth; an additional 457 records were matched using
the mother’s name and date of birth when the SSN match did not work. Because
numbers may be transposed or names misspelled, multiple matching approaches
can improve success rates when one field does not match.
alternatives when data entry of vital records is delayed or incomplete. It
may take a month or more for a newborn’s birth records to enter the vital
records database. However, a hospital record on hospital letterhead dated
close to the date of birth may also meet the documentation requirement.
A variety of
technical problems may confound data matches. For example, a state may not have
automated birth records for certain years or counties, and upgrading the systems
or databases could require significant time and resources. CMS recently
announced the availability of “Medicaid transformation” grants, which do not
require state matching funds. States could consider applying for such grants to
help improve their matching systems.
ways to turn near matches into successful matches. Techniques exist to
improve matching rates by overcoming non-matches that occur due to data entry
errors, such as transposed numbers or letters and slight variations in the
spelling of names. The National Association for State Public Health
Statistics and Information Systems (NASPHSIS) is exploring the use of
techniques that identify close (but not exact) matches, which can then be
reviewed more closely. For example, there is one matching technique, called
Soundex, that can help match names despite slight variations or errors in the
spelling of names (e.g., “Smith” vs. “Smyth.”).
ways to conduct data matching across states. The barriers created by the
Medicaid documentation requirement could be alleviated further if state
Medicaid agencies could conduct data matches with vital records agencies in
other states. NASPHSIS is partnering with a broad array of state and federal
agencies to develop a national system, called Electronic Verification of Vital
Events, that can check birth certificates across the nation. The system is
not expected to be ready until 2008, but NASPHSIS is investigating whether it
can be used to share information across a limited number of states before
In addition, some states are considering vital records data-sharing
reciprocity agreements with other states, particularly bordering states. This
would significantly expand the potential scope of vital records matches.
Ways to Improve Matching to Document Citizenship
While the interim final regulations offer some
important options to states, they do not give states options to develop or use
other innovative approaches to data matches, such as the following:
- More than 40 percent of all births in the
United States are paid for by Medicaid.
Medicaid claims data (or claims from Medicaid managed care organizations)
could be used to demonstrate when these babies have been born in U.S.
hospitals and thus are native-born citizens. CMS should consider giving
states the option to use electronic claims data to document citizenship for
- The Social Security Administration maintains
the NUMIDENT data system, which includes data on the place of birth for
virtually all people with Social Security numbers and citizenship data for
those who applied for a Social Security number after 1972. The Social
Security Administration has not made these data available to states and it is
not clear whether CMS has pursued discussions with SSA to make the data
available. These data could help states considerably because they indicate
place of birth (and often citizenship) no matter where a person was born. CMS
regulations could be modified to let states to use these data if they
eventually become available.
- Information from the Department of Homeland
Security’s Systematic Alien Verification of Entitlements (SAVE) system can be
used to document that a person is a naturalized citizen, although it has some
This approach can be particularly valuable for those who cannot find their
original Certificates of Naturalization, the principal form of documentation
permitted by CMS for naturalized citizens. Those who cannot find their
original certificate will otherwise have to pay a $220 replacement fee, and
obtaining the replacement can take up to a year. In comparison, a SAVE search
typically costs less than $1 and can be completed in less than a week.
Medicaid agencies generally already participate in SAVE, so this process is
readily available to them. CMS should allow this information to be used in
documenting that an applicant or beneficiary is a naturalized citizen. Under
the interim regulations, data from the SAVE system is not considered
satisfactory proof of citizenship.
Given how information-rich our nation is, it is
plausible that other data bases or approaches exist that also could help to
document citizenship. The interim final regulations do not accord flexibility
that would permit states to use other effective or efficient strategies.
The new Medicaid documentation requirement
creates difficult obstacles for U.S. citizens seeking to secure or retain
Medicaid coverage, as well as significant administrative burdens for states. It
could add to state administrative costs and cause substantial numbers of
Medicaid-eligible U.S. citizens to have their coverage delayed or denied.
States can mitigate the harmful effects of the
new requirement by adopting an option provided under the interim final
regulations to document individuals’ citizenship and identity through data
matches with existing state databases. Data matching has the potential to
document citizenship status for most children on Medicaid and for a large
fraction of adults. There also are a number of ways in which states can broaden
the scope or improve the effectiveness of data matching and thereby reduce
burdens and costs both on state administrators and on Medicaid applicants and
 Judith Solomon and Andy Schneider,
“HHS Regulation Focuses New Medicaid Documentation Requirement on U.S. Citizen
Families,” Center on Budget and Policy Priorities, July 13, 2006. Leighton Ku,
“Revised Medicaid Documentation Requirement Jeopardizes Coverage For 1 to 2
Million Citizens,” Center on Budget and Policy Priorities, July 13, 2006.
 71 Federal Register 39214 (July 12,
 42 CFR 435.407(b)(1).
 We excluded elderly and disabled
people since the Medicaid citizenship documentation rule effectively exempts
Medicare and SSI beneficiaries. Like any survey data, these estimates are
subject to sampling error. We thank Arloc Sherman of CBPP for tabulating these
 See Ku, July 13, 2006, for a
discussion of the data and methodology. Some of the 38 million current
beneficiaries will not seek renewal because they no longer have low incomes,
gained private insurance, or have other reasons.
 This estimate is based on two
analyses. CBPP analysis of 2003 Medical Expenditure Panel Survey data indicated
that about 24 percent of those enrolled in Medicaid over the course of a year
entered Medicaid after the year began; non-elderly adults and children are the
most likely to enter. Unpublished analyses by Urban Institute of the 2003
Medicaid Statistical Information System data yielded similar results: 26
percent of children and adults on Medicaid were found to have entered the
program after the first month of the year (personal communication with UI
researchers, August 2006).
 The regulations give states the
option of using matches with the State Data Exchange (SDX) — data from the
Social Security Administration about SSI recipients — to document the
citizenship and identity of SSI beneficiaries. This is most relevant in states
that do not automatically provide Medicaid eligibility to those on SSI:
Connecticut, Hawaii, Illinois, Indiana, Minnesota, Missouri, New Hampshire,
North Dakota, Ohio, Oklahoma, and Virginia. States already routinely receive
and use SDX data, so this should not be difficult for most states. Since the
remaining states automatically grant Medicaid to those receiving SSI benefits,
SSI recipients in those states are already exempt from the citizenship
 42 CFR 435.407(e)(10). The
regulations make the Medicaid agency responsible for the accuracy of this
 7 CFR 273.2 (f)(1)(vii).
 We spoke
with Medicaid officials in those states in July and August 2006 and gratefully
acknowledge their input.
 Plans to enter older data were
delayed due to other priorities that have arisen since Hurricane Katrina.
Fortunately, older records generally still exist because dedicated agency staff
moved the records to secure locations before flooding occurred.
 State Medicaid Director Letter
#06-012, June 9, 2006,
www.cms.hhs.gov/medicaid, states on page 12 that federal Medicaid matching
funds are available “for state expenditures to carry out the provisions of
section 1903(x)” of the Social Security Act, where the new citizenship
documentation requirement is set forth.
 A copy of the current U.S. standard
certificate of live birth is at
www.cdc.gov/nchs/data/dvs/birth11-03final-ACC.pdf. Actual forms used by
 Mary Alice Lee and Amanda Learned,
“Linking Birth and Medicaid Data for MCH Policy and Program Development,”
Connecticut Voices for Children, presentation at Association of Maternal and
Child Programs conference, Feb. 2005.
 42 CFR 435.407(c)(1).
 State Medicaid Director Letter
#06-017, July 25, 2006,
www.cms.hhs.gov/medicaid. Enabling Medicaid and vital records data systems
to interact would further the basic purpose of these grants, which is “to
develop innovative methods to improve effectiveness and efficiency in providing
medical assistance under Medicaid.”
 Soundex simplifies names by
disregarding the vowels and comparing consonants. In addition, consonants that
may sound alike (e.g., “c” and “k” or “s” and “z”) are grouped together. The
National Archives and Records Administration has more information on the use of
 Minnesota, Missouri, North Dakota,
Iowa, and South Dakota are EVVE pilot states. Garland Land, the association’s
director, can discuss possible projects with other states, using this platform ([email protected]).
Land also notes that states could apply for Medicaid Transformation grants to
upgrade their systems through the use of EVVE.
Kaiser Family Foundation, “Births Financed by Medicaid as a Percent of Total
 Checking SAVE normally requires that
the immigrant’s alien identification number or Certificate of Naturalization
number be submitted to check for a match, but matches can be conducted even if
these data are not available (although doing so is more difficult and less
likely to be effective). The online system does not include information on
naturalizations that occurred before 1975, although DHS has the ability to
search older records when necessary.