To crack down on illegal use of benefits, those eligible for plan must show proof of citizenship

Medicaid mandate nears start


Starting Saturday, millions of Americans who are eligible for Medicaid - including more than 700,000 poor Marylanders - will need to prove U.S. citizenship with driver's licenses, birth certificates or other documents to get or to keep their government health insurance.

The new federal mandate, part of the Deficit Reduction Act signed by President Bush in February, aims to crack down on undocumented immigrants who unlawfully receive Medicaid benefits.

But public health advocates in Maryland and around the country complain that the changes will hurt poor citizens who need health care most.

Those eligible for Medicaid, the nation's premier health care program for the poor, are predominantly children, elderly, disabled or homeless. The program also covers some poor working families who don't have insurance through their employer.

Although federal guidelines say states must enforce the new requirement by July 1, or risk losing funding, health officials in California and Ohio are threatening to delay implementation. And officials in Maryland are considering postponing enforcement until September for applicants renewing benefits.

Local agencies said they didn't find out about the new requirement until June 9, and they have been scrambling to educate the public and train staff on the changes.

Yesterday, the issue entered the legal arena with the filing of a class action lawsuit in federal court in Chicago claiming the requirements are unconstitutional.

John Bouman of the Sargent Shriver National Center on Poverty Law, which is representing the plaintiffs, blamed politicians for passing a requirement that "panders" to opponents of illegal immigration without considering the harm it will bring citizens.

"This is not about debating the point of immigration," Bouman said. "There is real damage that is happening here, and it will only get worse when this is implemented."

While only citizens can lawfully receive Medicaid, the federal government has not required documents to prove citizenship before providing coverage. Most states allow applicants to sign a declaration of citizenship.

Under the new system, Medicaid recipients must show documentation proving both their citizenship and identity such as a passport, a combination of birth certificate and driver's license or a birth certificate and medical record.

Advocates contend the neediest applicants - children in foster care, seniors in nursing homes and the homeless - don't possess those documents and will struggle to navigate the red tape.

"Someone who has dementia who is in a nursing home, what are the chances that they are going to be able to dig up their birth certificate, or that they have a passport?" said Dr. Joshua Sharfstein, Baltimore's health commissioner.

Maryland does not automatically issue birth certificates. Instead, families receive birth registration cards in the mail with information on how to purchase a birth certificate for $12.

Michelle Hoyt, 27, of East Baltimore, does not have a birth certificate or a driver's license. And she hasn't purchased a birth certificate for her 2-month-old daughter because she needed the money for necessities. Raising four children on $400 a month in child support payments, every penny counts, she said.

"The truth is, people like me, single moms on a fixed income, cannot afford to do this," she said.

Kathleen Westcoat, president of Baltimore HealthCare Access Inc., which assists Baltimore's nearly 200,000 Medicaid enrollees, said the requirements are a nightmare.

"Just the logistics of it is going to be a disaster," she said.

The agency receives about 3,000 applications for Medicaid coverage a month, mostly by mail. Westcoat envisions a scenario in which scores of applicants hoping to receive health insurance try to squeeze into the agency's tiny offices at 201 E. Baltimore St.

"We have one office assistant at our front desk, two chairs and no parking," she said.

At the Maryland Department of Health and Mental Hygiene, officials have yet to organize new procedures. The agency's deputy secretary for health care financing, who oversees the state's Medicaid program, resigned last week.

A spokesman for the agency said he left the department to pursue a teaching opportunity.

For now, the agency is scrutinizing federal guidelines to determine whether it can provide citizenship or identity proof using its own databases. For instance, they are hoping to use Medicaid claim records as citizenship documentation.

"Why do we want to make people obtain a birth certificate when we know they were born in the U.S. because we paid for it?" said Charles Lehman, who oversees eligibility issues in the state's Medicaid office.

The agency has organized town hall meetings, including one that will be held at 6 p.m. today at Baltimore Community College's Fine Arts Theater at 2901 Liberty Heights Ave. to explain the changes to advocates and recipients.

Stephen J. Allen, chief executive officer of Xavier Health Care Services, which operates nursing homes in Maryland, wants the department to go further and delay implementation for all enrollees - including new applicants.

He said without a guarantee that he will be paid, he will not accept new nursing home patients. And that, he said, may mean that the elderly poor could languish without needed medical attention.

"The hospital will have to keep the patient," he said, "or the patient will be discharged into an environment where there is no family or no caregivers. This is what we're facing."

S. Anthony McCann, Maryland's health secretary, said yesterday that the agency has little choice but to work hard to implement the new criteria.

"The debates whether this is a good idea or not a good idea occurred last year - they are not very productive right now," he said. "Congress has enacted the law, and we have to implement it."

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