Maternal and Child Health Access
1111 W. Sixth Street, Suite 400
Los Angeles, CA 90017-1800
Tel 213. 749. 4261
Fax 213. 745. 1040
info@mchaccess.org
July 28, 2006
Stan Rosenstein
Deputy Director
State Department of Health Services
1501 Capitol Avenue, Building 171
MS 4000, P.O. Box 942732
Sacramento, CA 94234-7320
DRACitiz@dhs.ca.gov
RE:
Draft ACL on DRA implementation of citizenship documentation requirements
Dear Mr. Rosenstein:
Thank you for the opportunity to comment on the draft All County Welfare Directors
Letter implementing the citizenship documentation requirements of the Deficit Reduction
Act of 2005. It is clear from the draft that the Department is making serious efforts to
attempt to mitigate the harms from this unnecessary federal law. MCH Access is joining
in with others in extensive comments under separate cover; in this letter, we would like to
highlight special concerns involving infants and individuals needing pregnancy-related
care.
(1) Deemed eligible infants
The draft ACL is silent on this issue. We recommend the following line edits to clarify this point
for the counties, providers and consumers that the new citizenship requirements do not apply to
these infants (additions in underline):
Page 3:
“The new federal requirement to document U.S. citizenship/national status does not apply
when establishing presumptive eligibility or accelerated enrollment or deemed eligibility
for infants.”
Page 12:
Presumptive Eligibility, Accelerated Enrollment for Children, and Minor Consent
“The new federal requirement to document U.S. citizenship/national status does not apply
to any individuals who are establishing presumptive eligibility or accelerated enrollment.
However, the evidence of citizenship/identity requirement is applicable when their
ongoing Medi-Cal eligibility is determined. The evidence of citizenship requirements
apply to prenatal services within the Minor Consent Program. Please note that Medi-Cal
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also offers a presumptive eligibility program for prenatal care that does not require
documentation of citizenship/identity.”
The new citizenship/identity documentation requirement does not apply to infants who
are "deemed eligible" for Medi-Cal. Counties should continue to follow existing
procedures for “deemed eligible” infants. See ACWDL No. 03-49.
(2) Deemed eligible infants after turning age one year
To qualify for “deemed eligibility”, a newborn must be born to a woman eligible for and
receiving Medi-Cal and must reside with the mother in the birth month. See ACWDL No. 03-49.
Medi-Cal pays primarily for hospital deliveries in California. Infants born in any state in the
U.S. are themselves U.S. citizens. Therefore, once the state has identified an infant as “deemed
eligible”, his or her citizenship has also been proved, as the Preamble to the federal interim
regulations conclude (page 12). Once citizenship has been proved for purposes of the DRA, it
need not be documented again at a Medi-Cal redetermination or after a break in Medi-Cal
eligibility.
We therefore recommend that the following also be added to the draft ACL at page 12:
. . . Counties should continue to follow existing procedures for “deemed eligible” infants.
See ACWDL No. 03-49.
In addition, the citizenship/identification requirements do not apply to a “deemed eligible”
infant who has turned age one year and is having his or her case redetermined or is applying
for Medi-Cal after a break in coverage at any age. This is because citizenship for a “deemed
eligible” infant has already been proved at birth, and once citizenship has been proved for
any Medi-Cal applicant or recipient it never needs to be proved again for Medi-Cal purposes.
(3) Limiting the application of the new citizenship documentation requirements in the
Minor Consent program to only those individuals and services for whom the state
claims FFP.
With respect to the Minor Consent program, the draft ACL has only the following very broad
statement: “The evidence of citizenship requirements apply to prenatal services within the Minor
Consent Program” (page 12). This statement should be narrowed and clarified to provide that
the new citizenship documentation requirements apply in the Minor Consent program only to
citizens in Aid Code 7N applying for or receiving prenatal care services.
The following suggested line edits for page 12 are intended to provide that clarification:
. . . For Minor Consent, the evidence of citizenship requirements apply only to citizen
applicants for or recipients of prenatal care services within the Minor Consent Program
Aid Code 7N. Please note that Medi-Cal also offers a presumptive eligibility program for
prenatal care that does not require documentation of citizenship/identity.
(4) Avoiding delays in access to prenatal care services for 7N citizen applicants
It will be very difficult for 7N citizen applicants seeking prenatal care services to obtain and
submit documentation of citizenship. We therefore propose that the draft ACL clarify that
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providers may use the Presumptive Eligibility Program for Pregnant Women for minors
whose follow-up applications for Medi-Cal will be through the Minor Consent 7N program.
This would allow minors to begin receiving prenatal care right away and provide at least a
window for collecting and submitting citizenship documentation with the follow-up Minor
Consent application.
The draft ACL should also include a reminder that providers can extend PE for two
months at a time when they know that the follow up Medi-Cal application has been submitted
to the county. (See Medi-Cal Provider Bulletin, Presumptive Eligibility, page 10; see also,
Welfare and Institutions Code § 14011.8(b) (after submission of the Medi-Cal application,
presumptive eligibility continues until a final eligibility determination is made.) Minor Consent
prenatal care providers will have or can get proof that the Minor Consent application has been
submitted. The reminder should make clear that successive periods of PE are available without
regard to whether an individual has submitted a regular Medi-Cal application or one for Minor
Consent. Once citizenship has been documented for any Medi-Cal applicant or recipient,
counties may not demand that it be documented again; therefore, extending PE to allow for
citizenship documentation would be a one-time event as well.
Suggested line edits for the draft ACL to reflect these points are:
Page 12:
. . .Please note that Medi-Cal also offers a presumptive eligibility program for prenatal
care that does not require documentation of citizenship/identity. The Presumptive
eligibility for prenatal care program is also available for minors seeking prenatal care
services under the Minor Consent Program’s Aid Code 7N. Counties and providers are
reminded that when a provider has proof that the follow-up Medi-Cal application
(whether a regular application or a Minor Consent application) has been submitted for a
prenatal care patient, the provider may extend presumptive eligibility for two months at a
time. See, Medi-Cal Provider Bulletin, Presumptive Eligibility, page 10.
In addition to the above recommendations for the draft ACL, we would like to discuss with the
Department options, such as a confidential mail-in or electronic application, for the
elimination of the requirement that Minor Consent applications (whether original or
follow-up) be made in person at the county welfare office.
Finally, it is imperative that the Department respond quickly to the request made by MCH
Access many months ago to drop the unlawful requirement that Minor Consent recipients
appear in person at the county welfare office each month in order for prenatal care
services to continue from month to month. The current practice violates state law on
continuous eligibility for children and pregnant women as well as Medicaid’s comparability
requirements.
(5) SB 24 implementation
Many of the problems identified above would be mitigated if the Department would
implement SB 24 (Stats. 2003, c. 895): providers would have an electronic “prenatal gateway” to
use to enroll patients to start PE and also to submit the follow-up application at the same time the
PE begins.
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SB 24 also provides for a Newborn Hospital Gateway through which “deemed eligible”
newborns could be enrolled into Medi-Cal for the entire first year of life directly from the
hospital.
We understand that four health care foundations and the Department have recently signed an
MOU to proceed with a feasibility study report for the SB 24 implementation. Now that the
resources have been provided to the Department, we urge you to move quickly to get the
necessary systems in place. The DRA has made the need for additional improvement in MediCal’s enrollment system even more urgent than ever.
Sincerely,
Lucy Quacinella
For MCH Access
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