OLR Research Report

May 17, 2007




By: Robin K. Cohen, Principal Analyst

You asked if the new federal proof of citizenship requirement for Medicaid eligibility has had an impact on enrollment for children or their caretaker relatives.


Since July 1, 2006, federal law has required the Department of Social Services (DSS) to obtain proof of citizenship before granting initial eligibility for Medicaid or redetermining eligibility for recipients. Citizenship was required previously, but clients could declare it without providing proof. While certain individuals are exempt from the new requirements, most children and their caretaker relatives applying for or receiving Medicaid (HUSKY A) are not.

Data from DSS show a significant rise in both the number of overdue applications and re-determinations for family Medicaid coverage (group that includes children in families with incomes up to 185% of the federal poverty level (FPL) and their caretaker relatives with incomes up to 150% of FPL) since July 2006. Indeed, DSS believes that the DSS eligibility reports make a “convincing case” that the delays are resulting from the citizenship requirements.

DSS has undertaken several initiatives to reduce the backlog and get applications and redeterminations processed sooner. These include working with the Department of Public Health (DPH) to match applications to birth records and designating community providers to reach out to clients to help them get the necessary documentation. Federal Medicaid matching funds are available to offset any related administrative costs. The governor's FY 08 budget includes an additional six positions in DSS to help with the citizenship requirements.


Section 6036 of the federal Deficit Reduction Act of 2005 (PL 109-171) requires certain people applying for or receiving Medicaid to document their U.S. citizenship and identity. Prior to the law's passage, proof was required but it could be offered simply through self-declaration, under penalty of perjury, with no documentation requirement. States not complying with this new requirement risk losing federal Medicaid matching funds (50% of program expenditures in Connecticut).

The law exempts a number of individuals, including those receiving Supplemental Security Income and Medicare. In general, families in which a child alone or a caretaker relative is applying for or already receiving Medicaid are subject to the new rules. (See Attachment 1 for a Voices for Children summary of those Medicaid-eligible individuals subject to the requirements and those who are exempt or may have additional time to get the documentation.)

Non-exempt individuals must document both their citizenship and identity. To prove citizenship, individuals must show one of several enumerated acceptable forms of proof, such as a U.S. passport or birth certificate. To prove identity, individuals may provide a state driver's license or one of several forms of identification the federal law allows states to accept.

The regulations allow states' Medicaid agencies (DSS in Connecticut) to electronically verify citizenship, such as searching birth record databases that are held by other state agencies (see below).


States were expected to start implementing the proof of citizenship and identity rules in July 2006. At that time, DSS reported that 2,920 family Medicaid (includes HUSKY A and certain others) applications were pending, as compared with 1,324 for aged, blind and disabled (ABD) Medicaid applicants and 1,430 applicants for long-term care Medicaid. In April 2007, the number of family cases pending rose to 4,753, a 63% increase. In contrast, the number of ABD cases stayed relatively constant (1,350) and pending long-term care applications rose more significantly (1,708, or 19%). These latter two groups of applicants are generally not subject to the new documentation requirements.

The new rules also apply when DSS annually re-determines whether a family still qualifies for Medicaid. This process begins in the 11th month of eligibility and is expected to be completed by the end of the 12th month. If a redetermination is not completed by that time, it is considered overdue. DSS data show that overdue redeterminations also rose between July 2006 and April 2007, from 3,962 to 17,227 (a 334% increase). The other Medicaid groups' (those generally exempt from citizenship documentation) redeterminations were also up but by a significantly smaller percentage.

Although the number of overdue family Medicaid redeterminations is considerably higher than the number of overdue applications, we should note that the federal regulations allow states to continue to cover families going through the redetermination process, provided they are making a good faith effort to produce the documentation. According to Kevin Loveland of DSS, DSS has not terminated any families for failure to produce citizenship documentation. Moreover, changes in Medicaid law (e.g., reduction of transitional Medicaid from two years to one) could be causing some of the redetermination backlog.


Loveland stated that DSS has undertaken a number of initiatives to help reduce the application and redetermination backlogs. It started a pilot program in the Waterbury and Bridgeport areas, partnering with the United Way to phone recipients with overdue redeterminations. The results from the pilot are due to DSS in mid-June.

The department is also conducting a data match with the Department of Public Health's (DPH) birth records registry for individuals born since January 1988. This match is currently being tested and should be running by the end of May or early June.

DPH also hired a consultant to put its birth records into a format that will make them accessible electronically. DPH intends to make the data available through the national Electronic Verification of Vital Events (EVVE) system. Once this is operating, DSS should be able to query and verify birth records. For several months, DSS has been doing this verification manually by sending DPH a form. It will continue to use this system for pre-1988 births until the EVVE system is available.

Additionally, DSS has designated certain community providers as “outstation locations,” as allowed by the federal regulations, to receive and do initial processing (secure verifications) for certain Medicaid

applications. The providers include all of DSS Healthy Start sites, and DSS is also allowing the “qualified entities” authorized to grant presumptive Medicaid eligibility to do this.

Matching federal Medicaid funds are available to pay for the costs of administering the documentation requirements. Loveland stated that at this point, the only increased costs DSS has incurred are related to the DPH match and verification procedures. DSS intends to reimburse DPH for the information technology consulting costs of developing the data match and for a microfilm reader for the manual matches. A memorandum of understanding is awaiting DPH's signature. DSS has not added any staff, but the governor's FY 08 budget includes six additional staff related to the additional documentation-related workload.