Fact Sheet: Citizenship Documentation Requirements under the Deficit Reduction Act and Interim Final Rule

I. Introduction
This fact sheet describes the citizenship documentation requirements found in the Deficit Reduction Act of 2005 (DRA), including the documents that can and must be used to verify citizenship for Medicaid eligibility purposes. Also, the fact sheet discusses recent developments in the implementation of the DRA citizenship documentation requirements, such as the release of the interim final regulations and the opinion issued in Bell v. Leavitt. Finally, it offers some advocacy strategies for advocates as their states implement the DRA.
II. The Deficit Reduction Act of 2005
To be eligible for full Medicaid benefits, an individual must be a citizen or national of the United States or a qualified legal immigrant. In the past, most states allowed U.S. citizens to attest to their citizenship under the penalty of perjury when applying for Medicaid benefits.2 States required documentation of citizenship only when there was a reason to question an applicant?s statement attesting citizenship.
On February 8, 2006, President Bush signed the DRA. Included in the DRA was a provision requiring applicants for and recipients of Medicaid who are U.S. citizens to provide documentation verifying their citizenship. Notably, this provision was added at the request of Representatives Charlie Norwood (R-Georgia) and Nathan Deal (R-Georgia) who claimed that they wanted to prevent undocumented immigrants from enrolling in Medicaid. However, a report by the HHS Office of the Inspector General found no substantial evidence that undocumented immigrants are fraudulently getting Medicaid coverage by claiming they are citizens. The report, thus, did not recommend requiring the documentation of citizenship. And state officials interviewed for the report noted that such a requirement would add significant administrative costs and burdens, requiring the hiring of additional eligibility personnel.3 On February 16, 2006, Senator Akaka (DHawaii) and others introduced S. 2305, a bill to repeal these provisions.
The citizenship documentation requirements, which were ultimately included in Section 6036 of the DRA, mandate that states document the U.S. citizenship of some, but not all, Medicaid participants. 4 Effective July 1, 2006, the provision applies to both new applicants and current recipients (at the time of recertification /redetermination), who declare themselves to be citizens or nationals of the United States under 42 U.S.C. § 1320b-7(d) for purposes of establishing Medicaid eligibility. The DRA provision conditions Federal Financial participation (FFP) on state verification of documentation, but does not actually change eligibility requirements for Medicaid. The DRA provision does not impose any new documentation requirements on non-citizen immigrants.5 Thus, on its face, the provision is not an eligibility requirement.
The statute allows states to use only certain documents to verify U.S. citizenship:
  • U.S. passport
  • Certificate of Naturalization (Form N-550 or N-570)
  • Certificate of U.S. Citizenship (Form N-560 or N-561)
  • A valid state-issued driver?s license or identity document described in 8 U.S.C. § 274A(b)(1)(D) (Immigration and Nationality Act), but only if the state requires proof of U.S. citizenship prior to issuance or obtains and verifies the individual?s Social Security Number
  • For individuals under age 16 or in a State which does not provide for issuance of an identification document (other than a driver?s license), documentation of personal identity of such other type as the U.S. Attorney General finds, by regulation, provides a reliable means of identification but only if the state requires proof of U.S. citizenship prior to issuance or obtains the individual?s Social Security Number and verifies its accuracy.
  • Such other documentation as the Secretary of HHS may allow by regulation that provides proof of U.S. citizenship/nationality and ?a reliable means of documentation of personal identity.

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