Under this provision, Medicaid  applicants and beneficiaries who are undergoing redeterminations of  eligibility must provide “satisfactory documentary evidence” of  citizenship. Under the regulations issued by CMS, states must provide applicants and  Medicaid beneficiaries a “reasonable opportunity” to document their  citizenship before denying or terminating Medicaid eligibility. States that reported a decline in enrollment  varied in their views of the effects on access to Medicaid coverage after  the first year of implementation. State enrollment policies and whether an  individual is an applicant or a beneficiary at redetermination are two  factors that may have influenced the effect of the requirement on  individuals’ access. Of the 44 states,  22 states reported a decline in enrollment due to implementing the  requirement, 12 reported no change in enrollment as a result of the  requirement, and 10 reported that they did not know the effect of the  requirement on enrollment (see fig. Overall, these denials and terminations represented over 18,000  individuals, who the state generally believed were eligible citizens. For example, states that  reported a previous reliance on mail-in applications and redeterminations  were more likely to report a decline in Medicaid enrollment. Another enrollment policy that may have influenced the requirement’s  effect on access to Medicaid coverage was the amount of time states  allowed individuals to comply with the requirement—otherwise known as  reasonable opportunity periods. In addition, applicants in some states were given less time than  beneficiaries to meet the requirement. States Reported Investing Resources to Implement Requirement, with Fiscal Benefits Uncertain

Although states reported investing resources to implement the  requirement, potential fiscal benefits for the federal government and states  are uncertain. State Resources Invested to Implement the Requirement and Assist Individuals with Compliance

All 44 states reported taking a number of administrative measures to  implement the requirement and assist individuals with compliance. Further, 15 states budgeted funds for implementation costs in  state fiscal year 2008. Two Aspects of the Requirement Increased the Burden of Implementation

Despite investments of resources, most states reported that the  requirement resulted in the state spending more time completing  applications and redeterminations and individuals needing more  assistance in person during the process. More than 80 percent of states (36 of 44) reported  facing administrative challenges in implementing the requirement, and  many attributed the challenges to two specific aspects of the requirement  outlined in the regulations, namely (1) that documents must be originals  and (2) that the list of acceptable documentation was complex and did not  allow for exceptions. Estimates of Federal and State Fiscal Benefits May Be Overstated

Though CMS expected some savings to result from the requirement in  fiscal year 2008, the estimate did not account for the cost to states and the  federal government to implement the requirement. Though CMS authorized  states to claim federal Medicaid matching funds for administrative  expenditures related to implementing the requirement, and 15 states  reported budgeting funds for 2008 in addition to the numerous other  measures being taken by states, CMS’s estimate of savings did not account  for any increase in administrative expenditures by states or the federal  government. When asked about potential savings from  the requirement, only 5 of the 44 states reported expecting the requirement  to result in a decrease in their expenditures for Medicaid benefits in state  fiscal year 2008, due in large part to individuals who appeared to be  eligible citizens who experienced delays in or lost coverage. Absent national  CMS data on the effects and because state Medicaid offices were largely  responsible for implementing the requirement, we determined they were  the best source for this information. Though not all states could quantify  the effect of the requirement on enrollment, 22 states reported that the  requirement resulted in decreases in enrollment, 12 reported that the  requirement had no effect on enrollment, and 10 reported not knowing the  effect of the requirement on enrollment. The report clearly  indicates that these data are from a single state and further notes that the  extent of the decline in Medicaid enrollment due to the requirement in  some individual states and nationally is unknown. At that time, we will send copies of this report  to the Secretary of HHS, the Administrator of the Centers for Medicare &  Medicaid Services, and other interested parties.
Why GAO Did This Study

The Deficit Reduction Act of 2005 (DRA) included a provision that requires states to obtain documentary evidence of U.S. citizenship or nationality when determining eligibility of Medicaid applicants and current beneficiaries; self-attestation of citizenship and nationality is no longer acceptable. The Centers for Medicare & Medicaid Services (CMS) issued regulations states must follow in obtaining this documentation. Interested parties have raised concerns that efforts to comply with the requirement will cause eligible citizens to lose access to Medicaid coverage and will be costly for states to implement. GAO was asked to examine how the requirement has affected individuals' access to Medicaid benefits and assess the administrative and fiscal effects of implementing the requirement. To do this work, GAO surveyed state Medicaid offices in the 50 states and the District of Columbia about their perspectives on access issues and the administrative and fiscal effects of the requirement. GAO obtained complete responses from 44 states representing 71 percent of national Medicaid enrollment in fiscal year 2004. GAO also reviewed federal laws, regulations, and CMS guidance.

What GAO Found

States reported that the citizenship documentation requirement resulted in barriers to access to Medicaid for some eligible citizens. Twenty-two of the 44 states reported declines in Medicaid enrollment due to the requirement, and a majority of these states attributed the declines to delays in or losses of Medicaid coverage for individuals who appeared to be eligible citizens. Of the remaining states, 12 reported that the requirement had no effect and 10 reported they did not know the requirement's effect on enrollment. Not all of the 22 states reporting declines could quantify enrollment declines due specifically to the requirement, but a state that had begun tracking the effect identified 18,000 individuals in the 7 months after implementation whose applications were denied or coverage was terminated for inability to provide the necessary documentation, though the state believed most of them to be eligible citizens. Further, states reporting a decline in enrollment varied in their impressions about the requirement's effect on enrollment after the first year of implementation. States' enrollment policies and whether an individual was an applicant or a beneficiary may have influenced the requirement's effect on access to Medicaid. For example, states that relied primarily on mail-in applications before the requirement were more likely to report declines in enrollment than states where individuals usually applied in person. In addition, the requirement may have more adversely affected applicants than beneficiaries because applicants were given less time to comply in some states and were not eligible for Medicaid benefits until they documented their citizenship. Although states reported investing resources to implement the requirement, potential fiscal benefits for the federal government and states are uncertain. All 44 states reported taking administrative measures to implement the requirement and assist individuals with compliance. In addition, 10 states reported that a total of $28 million was appropriated in state fiscal year 2007, and 15 states budgeted funds for implementation costs in state fiscal year 2008. Despite these measures, states reported that the requirement has increased the level of assistance needed by individuals and amount of time spent by states during the enrollment process. States specified two aspects of the requirement as increasing the burden for them and for individuals: that documents had to be originals and the list of acceptable documents was complex and did not allow for exceptions. Further, although CMS estimated the requirement would result in savings for the federal government and states of $90 million for fiscal year 2008, states' responses indicated that this estimate may be overstated for two reasons. Specifically, CMS did not account for the increased administrative expenditures reported by states, and the agency's estimated savings from ineligible, noncitizens no longer receiving benefits may be less than anticipated. In commenting on a draft of the report, CMS raised concerns about the conclusions drawn from the survey responses as to the requirement's effect on access, mainly that states did not submit data to support their responses.