```

[Congressional Record Volume 155, Number 7 (Tuesday, January 13, 2009)]
[Senate]
[Pages S345-S348]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. BINGAMAN (for himself and Mr. Akaka):
  S. 228. A bill to amend title XIX of the Social Security Act to 
permit States, at their option, to require certain individuals to 
present satisfactory documentary evidence of proof of citizenship or 
nationality for purposes of eligibility for Medicaid, and for other 
purposes; to the Committee on Finance.
  Mr. BINGAMAN. Mr. President I rise today with my colleague Senator 
Akaka to introduce legislation today designed to make several very 
important changes to current law to ensure that U.S. citizens receive 
the Medicaid to which they are entitled.
  Since July 1, 2006, most U.S. citizens and nationals applying for or 
renewing their Medicaid coverage face a new Federal requirement to 
provide documentation of their citizenship status. Recent reports 
indicate that tens-of-thousands of U.S. citizens, and in particular 
children, inappropriately are being denied Medicaid benefits simply 
because they don't have access to newly required documentation. The 
articles below and report by the Center on Budget and Policy Priorities 
highlight this very serious problem. Hospitals, physicians, and 
pharmacies may not be willing to treat these individuals until they 
have a source of payment, but they cannot qualify for Medicaid until 
they produce a birth certificate and ID.
  This new Federal requirement was added to Medicaid by the Deficit 
Reduction Act of 2005, DRA, enacted February 8, 2006. The Tax Relief 
and Health Care Act of 2006, TRHCA, signed into law December 20, 2006, 
included some amendments to the DRA citizenship documentation 
requirement, primarily to exempt certain groups. Prior to enactment of 
the DRA, states were permitted to use their discretion in requiring 
such citizenship documentation.
  Under Section 6036 of the DRA, citizens applying for or renewing 
their Medicaid coverage must provide ``satisfactory documentary 
evidence of citizenship or nationality.'' The DRA specifies documents 
that are acceptable for this purpose and authorizes the HHS Secretary 
to designate additional acceptable documents. No Federal matching funds 
are available for services provided to individuals who declare they are 
citizens or nationals unless the state obtains satisfactory evidence of 
their citizenship or determines that they are subject to a statutory 
exemption.
  According to a CRS Report for Congress updated April 15, 2008, 
``Based on a recent survey by the Government Accountability Office, 
GAO, 22 of 44 states report declines in enrollment due to the new 
citizenship documentation requirement. Based on another survey by the 
Kaiser Commission on Medicaid and the Uninsured, 13 states report a 
significant negative impact on enrollment and another 24 states report 
a modest impact. Among seven states detailed in an earlier report from 
the Center on Budget and Policy Priorities, only Wisconsin has a data 
system that

[[Page S346]]

can identify denials and terminations due to a lack of citizenship 
documentation, and it reports that about 19,000 people had their 
Medicaid eligibility denied or terminated for this reason between July 
31, 2006, and March 1, 2007.''
  A second wave study conducted from September 2007-March 2008 by the 
Department of Health Policy at the George Washington University School 
of Public Health published October 2008, ``Another distressing finding 
is the impact the citizenship documentation requirements appear to be 
having on SCHIP. Many states, for important reasons, use joint 
applications for both Medicaid and separate SCHIP programs. The effect, 
however, is to apply the citizenship documentation requirements to both 
programs, thereby delaying coverage for both groups of children.''
  ``Even if most or all of the reported Medicaid enrollment declines 
are due to the citizenship documentation requirement, a key question is 
whether the people who are being denied, terminated, or deterred from 
applying are U.S. citizens, rather than unauthorized aliens or other 
ineligible noncitizens. Of the 22 states reporting enrollment declines 
to GAO, a majority (16 states) attribute them to Medicaid coverage 
delays or losses for people who appear to be U.S. citizens.''
  It is important to note that citizenship documentation requirements 
do not affect Medicaid rules relating to immigrants--they apply to 
individuals claiming to be citizens. Most new legal immigrants are 
excluded from Medicaid during their first five years in the U.S. and 
undocumented immigrants remain eligible for Medicaid emergency services 
only.
  The legislation I am introducing would make several very important 
changes to current law to ensure that U.S. citizens receive the 
Medicaid to which they are entitled.
  First, the legislation would restore citizenship verification to a 
state option. Specifically, states would be permitted to determine when 
and to what extent citizenship verification is required of U.S. 
Citizens. States would also be permitted to utilize the standards most 
appropriate to the their population as long as such standards were no 
more stringent than those currently used by the Social Security 
Administration and includes native American tribal documents when 
appropriate.
  Second, the legislation would ensure that individuals are afforded a 
reasonable time period to provide citizenship documentation utilizing 
the same reasonable time period standard that is available to legal 
immigrants to provide satisfactory evidence of their immigration 
status.
  Third, the legislation protects children who are U.S. citizens by 
virtue of being born in the United States from being denied coverage 
after birth because of citizenship verification requirements.
  Fourth, the legislation also clarifies ambiguities in Federal law to 
ensure that these citizen children, regardless of the immigration 
status of their parents, are treated like all other low-income children 
born in the United States and are deemed eligible to receive Medicaid 
services for one year.
  Finally, the legislation also ensures that the thousands of citizen 
children and adults, who were erroneously denied Medicaid coverage, may 
receive retroactive Medicaid eligibility for coverage they were 
inappropriately denied because of citizenship verification 
requirements.
  I urge my colleagues in the Senate to support this critical 
legislation, which protects low-income U.S. citizens from being 
inappropriately denied Medicaid coverage because of lack of 
documentation.
  Mr. President, I ask unanimous consent that the text of the bill and 
letters of support be printed in the Record.
  There being no objection, the material was ordered to be printed in 
the Record, as follows:

                                 S. 228

       Be it enacted by the Senate and House of Representatives of 
     the United States of America in Congress assembled,

     SECTION 1. STATE OPTION TO REQUIRE CERTAIN INDIVIDUALS TO 
                   PRESENT SATISFACTORY DOCUMENTARY EVIDENCE OF 
                   PROOF OF CITIZENSHIP OR NATIONALITY FOR 
                   PURPOSES OF ELIGIBILITY FOR MEDICAID.

       (a) In General.--Section 1902(a)(46) of the Social Security 
     Act (42 U.S.C. 1396a(a)(46)) is amended--
       (1) by inserting ``(A)'' after ``(46)'';
       (2) by adding ``and'' after the semicolon; and
       (3) by adding at the end the following new subparagraph:
       ``(B) at the option of the State and subject to section 
     1903(x), require that, with respect to an individual (other 
     than an individual described in section 1903(x)(1)) who 
     declares to be a citizen or national of the United States for 
     purposes of establishing initial eligibility for medical 
     assistance under this title (or, at State option, for 
     purposes of renewing or redetermining such eligibility to the 
     extent that such satisfactory documentary evidence of 
     citizenship or nationality has not yet been presented), there 
     is presented satisfactory documentary evidence of citizenship 
     or nationality of the individual (using criteria determined 
     by the State, which shall be no more restrictive than the 
     criteria used by the Social Security Administration to 
     determine citizenship, and which shall accept as such 
     evidence a document issued by a federally-recognized Indian 
     tribe evidencing membership or enrollment in, or affiliation 
     with, such tribe (such as a tribal enrollment card or 
     certificate of degree of Indian blood, and, with respect to 
     those federally-recognized Indian tribes located within 
     States having an international border whose membership 
     includes individuals who are not citizens of the United 
     States, such other forms of documentation (including tribal 
     documentation, if appropriate) that the Secretary, after 
     consulting with such tribes, determines to be satisfactory 
     documentary evidence of citizenship or nationality for 
     purposes of satisfying the requirement of this 
     subparagraph));''.
       (b) Limitation on Waiver Authority.--Notwithstanding any 
     provision of section 1115 of the Social Security Act (42 
     U.S.C. 1315), or any other provision of law, the Secretary of 
     Health and Human Services may not waive the requirements of 
     section 1902(a)(46)(B) of such Act (42 U.S.C. 
     1396a(a)(46)(B)) with respect to a State.
       (c) Conforming Amendments.--Section 1903 of such Act (42 
     U.S.C. 1396b) is amended--
       (1) in subsection (i)--
       (A) in paragraph (20), by adding ``or'' after the 
     semicolon;
       (B) in paragraph (21), by striking ``; or'' and inserting a 
     period; and
       (C) by striking paragraph (22); and
       (2) in subsection (x)--
       (A) by striking paragraphs (1) and (3);
       (B) by redesignating paragraph (2) as paragraph (1);
       (C) in paragraph (1), as so redesignated, by striking 
     ``paragraph (1)'' and inserting ``section 1902(a)(46)(B)''; 
     and
       (D) by adding at the end the following new paragraph:
       ``(2) In the case of an individual declaring to be a 
     citizen or national of the United States with respect to whom 
     a State requires the presentation of satisfactory documentary 
     evidence of citizenship or nationality under section 
     1902(a)(46)(B), the individual shall be provided at least the 
     reasonable opportunity to present satisfactory documentary 
     evidence of citizenship or nationality under this subsection 
     as is provided under clauses (i) and (ii) of section 
     1137(d)(4)(A) to an individual for the submittal to the State 
     of evidence indicating a satisfactory immigration status.''.

     SEC. 2. CLARIFICATION OF RULES FOR CHILDREN BORN IN THE 
                   UNITED STATES TO MOTHERS ELIGIBLE FOR MEDICAID.

       Section 1903(x) of such Act (42 U.S.C. 1396b(x)), as 
     amended by section 1(c)(2), is amended--
       (1) in paragraph (1)--
       (A) in subparagraph (C), by striking ``or'' at the end;
       (B) by redesignating subparagraph (D) as subparagraph (E); 
     and
       (C) by inserting after subparagraph (C) the following new 
     subparagraph:
       ``(D) pursuant to the application of section 1902(e)(4) 
     (and, in the case of an individual who is eligible for 
     medical assistance on such basis, the individual shall be 
     deemed to have provided satisfactory documentary evidence of 
     citizenship or nationality and shall not be required to 
     provide further documentary evidence on any date that occurs 
     during or after the period in which the individual is 
     eligible for medical assistance on such basis); or''; and
       (2) by adding at the end the following new paragraph:
       ``(3) Nothing in subparagraph (A) or (B) of section 
     1902(a)(46), the preceding paragraphs of this subsection, or 
     the Deficit Reduction Act of 2005, including section 6036 of 
     such Act, shall be construed as changing the requirement of 
     section 1902(e)(4) that a child born in the United States to 
     an alien mother for whom medical assistance for the delivery 
     of such child is available as treatment of an emergency 
     medical condition pursuant to subsection (v) shall be deemed 
     eligible for medical assistance during the first year of such 
     child's life.''.

     SEC. 3. EFFECTIVE DATE.

       (a) Retroactive Application.--The amendments made by this 
     Act shall take effect as if included in the enactment of the 
     Deficit Reduction Act of 2005 (Public Law 109-171; 120 Stat. 
     4).
       (b) Restoration of Eligibility.--In the case of an 
     individual who, during the period that began on July 1, 2006, 
     and ends on the date of enactment of this Act, was determined 
     to be ineligible for medical assistance

[[Page S347]]

     under a State Medicaid program solely as a result of the 
     application of subsections (i)(22) and (x) of section 1903 of 
     the Social Security Act (as in effect during such period), 
     but who would have been determined eligible for such 
     assistance if such subsections, as amended by sections 1 and 
     2, had applied to the individual, a State may deem the 
     individual to be eligible for such assistance as of the date 
     that the individual was determined to be ineligible for such 
     medical assistance on such basis.
                                  ____

                [From the New York Times, June 5, 2006]

            Medicaid Rules Toughened on Proof of Citizenship

                            (By Robert Pear)

       Washington, June 4.--The Bush administration plans this 
     week to issue strict standards requiring more than 50 million 
     low-income people on Medicaid to prove they are United States 
     citizens by showing passports or birth certificates and a 
     limited number of other documents.
       The new standards follow a tussle with Congress. Federal 
     health officials had considered giving states broad 
     discretion to accept affidavits in place of official 
     documents. But House Republicans complained, and the 
     administration backed off, allowing affidavits ``only in rare 
     circumstances.''
       The requirements, which take effect July 1, carry out a law 
     signed by President Bush on Feb. 8.
       They vividly illustrate how concern about illegal 
     immigration is affecting domestic social welfare policy. The 
     purpose of the law was to conserve federal money for 
     citizens, reducing the need for states to cut Medicaid 
     benefits or limit eligibility.
       Gov. Rick Perry of Texas won enthusiastic applause at a 
     state Republican convention on Friday when he vowed to 
     increase border security and said, ``Texas will start 
     requiring every Medicaid applicant to verify that they are in 
     the country legally in order to receive benefits.''
       But officials in some other states and advocates for the 
     poor said the new requirements could cause hardship for 
     children, older Americans and poor people born at home in 
     rural areas who never received birth certificates. Children 
     account for about half of Medicaid recipients. People 65 and 
     older account for about 10 percent.
       Jennifer M. Ng'andu, a health policy specialist at the 
     National Council of La Raza, a Hispanic rights group, said, 
     ``The documentation requirements will cause confusion about 
     eligibility and will put up barriers to enrollment.''
       In general, Medicaid is available only to United States 
     citizens and to certain ``qualified aliens.'' Before the new 
     standards, in many states, people who declared they were 
     citizens did not have to support the claim.
       But in a letter being sent this week to state officials, 
     the Bush administration says, ``Self-attestation of 
     citizenship and identity is no longer an acceptable 
     practice.''
       In the law, Congress listed examples of documents that 
     could be used to show citizenship, and it said the secretary 
     of health and human services could ``by regulation'' specify 
     other acceptable documents.
       The main proponents of the new requirements were two 
     Republican House members from Georgia, Representatives 
     Charlie Norwood and Nathan Deal.
       John E. Stone, a spokesman for Mr. Norwood, said Sunday: 
     ``Charlie provided feedback to the administration in the last 
     two weeks to make sure the regulations would not undermine 
     the intent of the law. Obviously you need some flexibility so 
     that a 92-year-old woman with Alzheimer's does not get kicked 
     off Medicaid. What's unacceptable is for people to claim 
     benefits or sign affidavits swearing they are citizens 
     without any verification.''
       In an interview Sunday, Dr. Mark B. McClellan, 
     administrator of the Centers for Medicare and Medicaid 
     Services, said, ``We want to provide an effective way to 
     document citizenship without placing excessive burdens on 
     states or beneficiaries.''
       In the letter to state Medicaid directors, the 
     administration says, ``An applicant or recipient who fails to 
     cooperate with the state in presenting documentary evidence 
     of citizenship may be denied or terminated'' from the 
     program.
       The requirements will be enforced when a person applies for 
     Medicaid or when eligibility is first recertified on or after 
     July 1. In general, applicants and recipients will have 45 
     days to provide documents. People with disabilities will have 
     90 days.
       States typically redetermine eligibility every 3 to 12 
     months. ``Once citizenship has been proved, it need not be 
     documented again'' because it does not normally change, the 
     administration said.
       But the guidelines include a significant ambiguity: ``An 
     individual who is already enrolled in Medicaid will remain 
     eligible if he or she showed a good-faith effort to present 
     satisfactory evidence of citizenship and identity, even if 
     this effort takes longer than 45 days.'' The administration 
     says that ``beneficiaries will not lose benefits as long as 
     they are undertaking a good-faith effort to provide 
     documentation.''
       States have a strong incentive to enforce the requirements. 
     If they fail to do so, they can lose federal Medicaid money.
       The guidelines say states should help people document 
     citizenship, especially if they are homeless, mentally 
     impaired or physically incapacitated and have no one to act 
     on their behalf.
       The guidelines list four categories of documents that can 
     be used as evidence of citizenship, from the most reliable to 
     the least trustworthy. The best evidence, they say, is a 
     United States passport or a certificate of naturalization. 
     The next category includes state and local birth certificates 
     and State Department documents issued to children born abroad 
     to United States citizens.
       The third category consists of nongovernment documents 
     showing place of birth. These include medical records from 
     doctors, hospitals and clinics; nursing home admission 
     papers; and records from life and health insurance companies.
       The fourth category includes affidavits, which can be used 
     ``only in rare circumstances when the state is unable to 
     secure evidence of citizenship'' from other sources.
       ``An affidavit must be supplied by at least two 
     individuals, one of whom is not related to the applicant or 
     recipient,'' the guidelines say. ``Each must attest to having 
     personal knowledge of the events establishing the applicant's 
     or recipient's claim of citizenship. The individuals making 
     the affidavit must be able to provide proof of their own 
     citizenship and identity.''
       People signing affidavits may also be asked ``why 
     documentary evidence of citizenship does not exist or cannot 
     be readily obtained.''
                                  ____

                [From the Birmingham News, Dec. 4, 2006]

 Medicaid Rules Put Pinch On Poor, Lack of Proof Needed for Plan Keeps 
                             Many From Help

                           (By Kim Chandler)

       The four children in her office needed immunizations. But 
     because their mother did not have their original birth 
     certificates, and couldn't buy a copy, the family could not 
     enroll in Medicaid, Dr. Marsha Raulerson said.
       The children did not get their shots.
       During September and October, 1,600 low-income people, many 
     of them children, were rejected by Alabama's Medicaid program 
     because of tougher federal rules. They require applicants to 
     show an original birth certificate or a copy purchased from 
     the state Health Department with a raised seal, plus a 
     driver's license or other proof of citizenship and identity 
     when signing up for Medicaid benefits.
       Many more people eventually could lose benefits if they 
     can't produce the necessary documents.
       The new rules took effect July 1 and are part of the 2005 
     Deficit Reduction Act. Congress approved the law because of 
     concern that illegal immigrants were signing up for Medicaid 
     en masse. Instead of curbing widespread fraud, advocates 
     argue, the new rules deter poor U.S. citizens from getting 
     health coverage.
       ``Under the best of circumstances, many people would be 
     surprised to have to produce documentation of their 
     citizenship,'' said Jim Carnes of Alabama Arise, an advocacy 
     group for the poor.
       Alabama Medicaid Commissioner Carol Herrmann-Steckel said 
     the state is working hard to keep people on the Medicaid 
     rolls. Unlike some other states, Alabama is not kicking 
     current Medicaid recipients off the program if they do not 
     possess the necessary documents. Under a provision called 
     ``reasonable assurance,'' current Medicaid recipients are 
     allowed to temporarily re-enroll. Medicaid beneficiaries must 
     re-enroll every year.
       ``We are doing everything we can to verify citizenship. We 
     want to be fair to the Alabamians who are on Medicaid,'' 
     Herrmann-Steckel said. However, federal government officials 
     have not said how long the ``reasonable assurance'' period 
     could last. The number of people who could lose Medicaid 
     benefits would be ``significant.'' Herrmann-Steckel said.
       Medicaid is a joint federal-state health care program for 
     the poor and disabled, and it is a major provider of medical 
     care in Alabama. Medicaid pays for the health care of nearly 
     1 million Alabamians, about 20 percent of the state's 
     population, Herrmann-Steckel said.
       Advocates fear many poor people can no longer enroll in 
     Medicaid because they cannot locate their birth certificate, 
     or afford to buy a copy, and do not have the required proof 
     of citizenship such as a photo ID.
       The cost of obtaining a birth certificate is a challenge 
     for many low-income people, Carnes said, as is transportation 
     to present the documents. The state Department of Public 
     Health charges $12 to search for a birth certificate.
       There is currently no way to tell if the 1,600 who were 
     denied coverage were illegal immigrants or U.S. citizens 
     without the proper documents. But anecdotal evidence from 
     Medicaid workers suggests some were just poor American 
     parents. Medicaid workers asked people who had been denied 
     coverage why they didn't have the proper paperwork.
       ``By and large the reason was, `I can't afford to buy four 
     birth certificates,' '' said Lee Rawlinson, deputy Medicaid 
     commissioner for beneficiary services.
       Herrmann-Steckel said the state is doing everything 
     possible to help Medicaid-eligible people obtain the 
     documents.
       The Department of Public Health has agreed to begin faxing 
     Medicaid officials copies of birth certificates as a last 
     resort for applicants who can't obtain their own. The two 
     agencies will split the cost.
       Transportation also is a problem for some families, Carnes 
     said. While people previously could renew their Medicaid 
     status by

[[Page S348]]

     mail, the new rules require a trip to see a Medicaid 
     eligibility worker in person.
       ``There are all sorts of barriers, particularly for people 
     without transportation and who may not have had a documented 
     birth to begin with,'' Carnes said.
       Raulerson said she cares for a family in Monroe County that 
     once had Medicaid benefits but, without a car, has not been 
     able to renew their coverage.
       Medicaid officials say they don't know how many Alabamians 
     have lost their Medicaid benefits because they couldn't, or 
     didn't, visit an eligibility worker.
       The Alabama Medicaid Agency is also working with other 
     state agencies, such as the Department of Mental Health and 
     Mental Retardation, to see if they've already verified a 
     person's citizenship, she said.
       People who also receive Medicare, the health care program 
     for seniors, or Supplemental Security Income for a disability 
     were exempted from the requirements after state Medicaid 
     officials from across the country complained that would be 
     too burdensome.
       Other states are struggling to comply as well.
       California has yet to implement the new federal rules. 
     Vermont and other states are phasing in the regulations. 
     While the law was designed to cut down on Medicaid fraud by 
     illegal immigrants, Herrmann-Steckel said she does not 
     believe Alabama has a widespread problem of illegal aliens 
     receiving Medicaid.
                                  ____

              New Medicaid Rules Could Cost State Millions

                            (By John Hanna)

       The state could face millions of dollars in additional 
     costs because of federal rules requiring Medicaid recipients 
     to verify their citizenship, Gov. Kathleen Sebelius said 
     Wednesday.
       Sebelius said she's worried the state will have to pick up 
     the full cost of caring for some poor, frail and elderly 
     Kansans who are living in nursing homes, instead of sharing 
     the cost with the federal government. Also, she said, she 
     will propose adding state employees to verify the citizenship 
     status of Medicaid recipients and applicants.
       The governor told reporters she hopes Congress reviews the 
     issue and other attempts to prevent illegal immigrants from 
     obtaining social services or using driver's licenses as 
     identification.
       ``There was no input from the states on how realistic these 
     were or what the cost was,'' Sebelius said during a brief 
     news conference following an unrelated meeting.
       Under Medicaid requirements that took effect July 1, 
     recipients must provide either a passport or two other 
     documents, such as a birth certificate and a driver's 
     license, to verify citizenship.
       While the measure is targeted at illegal immigrants, some 
     advocates for the needy have worried that citizens will 
     either lose or be denied services because they have trouble 
     finding the necessary documents.
       State officials say the number of Kansans covered by 
     Medicaid dropped almost 7 percent since July 1, down to 
     253,000 from 271,000. They believe much of the decline can be 
     attributed to the new requirements.
       Typically, every $1 the state spends on Medicaid is matched 
     by about $1.50 from the federal government. If someone loses 
     their coverage, then the state faces paying the entire bill 
     for their services, Sebelius said.
       ``You're at 100 percent state dollars or push them out the 
     door,'' she said.
       Also, Sebelius said, the state needs to ``ramp up'' its 
     staffing to handle the additional verification work. The 
     governor is working on the budget proposal she'll submit to 
     the 2007 Legislature, which convenes Jan. 8.
       ``We're certainly going to put some of them in place,'' she 
     said. ``We're trying to make a careful analysis of how many 
     we need.''
       She said that if the state refuses to comply with the law, 
     it could face the loss of all federal health care dollars.
       ``We don't have a lot of latitude to say we're not going to 
     do this,'' she said. ``There are literally hundreds of 
     millions of dollars at stake.''
       Meanwhile, Sebelius expressed concern about a federal law 
     on driver's licenses passed last year.
       Starting in 2008, federal agencies won't treat a state's 
     licenses as valid ID unless a state requires license 
     applicants to document that they're living in the United 
     States legally. Lack of ID could prevent someone from 
     entering a federal building or boarding a plane.
       Sebelius said the law will require local driver's licenses 
     offices to certify that someone has the proper documentation 
     and to store the information.
       ``Exactly how that's going to happen, we're not quite 
     sure,'' Sebelius said. ``We don't basically have any of the 
     equipment that's required to do that in any of the rural 
     areas.''
                                  ____

      Thousands in Kansas Off Medicaid Following Citizenship Rules

       Thousands of low-income Kansans have lost or been denied 
     state health care coverage because of new rules requiring 
     them to prove they are American citizens, state officials 
     say.
       Since the federally mandated rules took effect July 1, the 
     number of Medicaid recipients in Kansas has decreased by 
     about 18,000, to 253,000. While officials can't determine 
     exactly how much of the 7 percent drop can be attributed to 
     the new rules, they believe much of it can.
       ``The impact to the consumer has been severe,'' said John 
     Anzivino, a vice president for MAXIMUS, a Reston, Va., 
     company that helps administer the joint federal-state 
     Medicaid program in Kansas. ``From our perspective, this has 
     possibly been the most dramatic change and challenge to the 
     Medicaid program since its inception.''
       The new rules were included in last year's federal deficit 
     reduction law and were designed to prevent illegal immigrants 
     from enrolling in the state programs providing health 
     coverage.
       But consumer advocates said many vulnerable people who 
     legitimately were eligible for assistance would lose coverage 
     because they couldn't produce the necessary documentation.
       ``We expect that many of these that have lost coverage will 
     regain coverage once they have gathered and provided the 
     necessary documentation,'' Marcia Nielsen, executive director 
     of the Kansas Health Policy Authority, told the Lawrence 
     Journal-World. ``They will, however, experience a gap in 
     coverage that could prove to be significant for some.''
       Medicaid applicants can prove their citizenship by 
     providing a passport. Or they can provide other documents 
     that verify both their citizenship, such as a birth 
     certificate, and their identities, such as a driver's 
     license.
       Anzivino said most people seeking benefits don't have a 
     passport and are left scrambling to find birth certificates 
     and other documents:
       The number of calls each month to a Kansas Medicaid 
     clearinghouse has more than doubled to 49,000 from 23,000, 
     official said.
       Meanwhile, Rep. Dennis Moore, a Democrat whose district is 
     centered on the state's portion of the Kansas City area, said 
     federal officials were aware of states' problems with the new 
     rules and probably would work on it when the new Congress 
     takes office in January.

                          ____________________
```