Efforts to provide health coverage for uninsured children eligible for Medicaid are being complicated by a proof of citizenship provision in the Deficit Reduction Act of 2005, according to an annual survey of State Children's Health Insurance Programs and Medicaid, released Jan. 9 by the Kaiser Commission on Medicaid and the Uninsured.
In general, the report found that states are showing renewed enthusiasm for covering the uninsured, especially children, said Diane Rowland, executive vice president of Kaiser Family Foundation and director of KCMU, and Donna Cohen Ross, director of outreach for the Center on Budget and Policy Priorities.
One in four American children depends on Medicaid and SCHIP for health coverage, Rowland said. However, the report indicated that 74 percent of eligible uninsured children from low-income families are not currently enrolled in either program.
Barriers such as lagging eligibility for low-income parents and failure to facilitate enrollment processes have contributed to the rising number of uninsured children, the report said.
But the largest barrier to enrollment identified by the Kaiser commission is the citizenship policy in the Centers for Medicare and Medicaid Services' Interim Final Rule on the deficit reduction act issued last July. The provision requires potential Medicaid enrollees to provide either primary evidence of citizenship, such as a U.S. passport, or secondary evidence, such as a birth certificate.
"The important thing for people to understand is really how hard this requirement is to meet," Ross said. Because this provision introduces hurdles associated with obtaining and submitting documents, "states are beginning to report declines in enrollment because they can't be processed in a timely manner," she said.
CMS spokesperson Jeff Nelligan said that CMS is not aware of any data that shows there are significant barriers to enrollment. “If states are experiencing difficulties, they should bring them to our attention as we certainly want to understand why they are not using the flexibilities we have provided,” he said.
According to the CMS rule, "States may accept original documentation in person, by mail, or by a guardian or authorized representative." Ross added that the original wording of the deficit reduction act did not include the requirement for original documents and not copies.
"Although the DRA does not direct it, the regulation requires states to seek the highest-level evidence available," the Kaiser commission stated in a Medicaid fact sheet listing the key provisions of the CMS rule.
Ross noted that no states reduced income eligibility for SCHIP and Medicaid in 2006. Several states, including Massachusetts and Illinois, made strong efforts to improve their programs for uninsured children.
"It's especially important to look at these results in light of the fact that many SCHIP programs are up for renewal this year," said Rowland.
Two critical success factors in states' programs are the availability of federal and state funding and the ability of states to design flexible systems to facilitate enrollment, Ross said.
"Some of the states that were set to experience shortfalls got some relief, but the help they got will only take them through May," said Ross. "For the country to be able to keep SCHIP enrollment even just where it is without losing kids, additional funds are needed."