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MEDICAID AND IMMIGRATION, JEAN SHEIL, CENTER FOR MEDICAID AND STATE OPERATIONS HOUSE COMMITTEE ON ENERGY AND COMMERCE - FIELD HEARING - DALTON GEORGIA Thank you for inviting me to speak with you about the impact of undocumented immigrants on the Medicaid program and the health care delivery system and express the Administration’s support for comprehensive immigration reform that increases border security, establishes a robust interior enforcement program, creates a temporary worker program, and addresses the problem of the estimated 11 to 12 million illegal immigrants already in the country. Medicaid is a partnership between the Federal government and the states. While the Federal government provides financial matching payments to the states, each state is responsible for overseeing its Medicaid program, and each state pays a portion of its cost through a statutorily determined matching rate, currently ranging between 50 and approximately 76 percent. The Centers for Medicare & Medicaid Services (CMS), which oversees the Federal responsibility for Medicaid, ensures states enforce Medicaid eligibility requirements. Recently, CMS issued guidance and an interim final regulation to the states as part of the implementation of the Deficit Reduction Act of 2005 (DRA), which requires Medicaid applicants who declare they are citizens to document their citizenship and identity. CMS, in regards to the broader health care system, also enforces regulations that require hospitals to medically screen and provide stabilizing treatment or an appropriate transfer to any person seeking emergency care, regardless of payment method or citizenship status. Immigrants and Medicaid Eligibility The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) significantly changed the eligibility of non-citizens for Federal means-tested public benefits, including Medicaid and subsequently the State Children's Health Insurance Program (SCHIP). This change, however, did not alter eligibility for undocumented and nonimmigrant aliens, who generally remain ineligible for non-emergency Federal benefits. As a general rule, only “qualified aliens” may be eligible for Medicaid and SCHIP coverage. Qualified aliens include aliens lawfully admitted for permanent residence under the Immigration and Nationality Act. Refugees, those granted asylum, and victims of a severe form of trafficking (as certified by the Office of Refugee Resettlement of the Department of Health and Human Services) among several other categories also may be considered qualified aliens. Under PRWORA, states are required to provide Medicaid to certain qualified aliens who otherwise meet the eligibility criteria of the state’s Medicaid program, unless subject to a five-year bar. This five-year bar applies only to qualified aliens who entered the However, the five-year bar and other eligibility restrictions do not apply to aliens who are applying only for treatment of an emergency medical condition. Thus, all aliens – both qualified and non-qualified aliens (including undocumented immigrants) – may be eligible for treatment of an emergency medical condition, provided they otherwise meet the eligibility criteria (such as income level, for example) for the state’s Medicaid program. CMS Issues Guidance on Citizenship and Identity Documentation for Medicaid Eligibility American citizenship or legal immigration status have, for many years, been a requirement for Medicaid eligibility. However, previously, in many states applicants could assert their citizenship status by merely checking a box on a form. (A number of states have long required their applicants to document citizenship, including In order to give states some initial guidance on the implementation of this provision, on June 9, 2006 CMS issued a State Medicaid Director letter. On July 12, 2006 the Department published an interim final regulation for states to implement this new requirement. Comments on the interim final rule are due on August 11, 2006. We expect to publish a final rule shortly. The law requires that a person provide evidence of both citizenship and identity. In some cases, a single document will be enough to establish both citizenship and identity, such as a The law specifies certain forms of acceptable evidence of citizenship and identity and provides for the use of additional forms of documentation as established by Federal regulations, when appropriate. If an applicant or recipient presents evidence from the listing of primary documentation, such as a At the time of application or re-determination, the state must give an applicant or recipient a “reasonable opportunity” to present documents establishing As with other Medicaid program requirements, states must implement an effective process for assuring compliance with documentation of citizenship in order to obtain federal matching funds, and effective compliance will be part of Medicaid program integrity monitoring. In particular, audit processes will track the extent to which states rely on lower categories of documentation with the expectation that such categories would be used relatively infrequently and less often over time, as State processes and beneficiary documentation improve. When future automated capabilities to verify citizenship and identity of Medicaid applicants becomes available, states also will be required to match for individuals who used third or fourth tier documents to verify citizenship and identity. In the meantime, states must ensure that all case records within this category are identified so that they may be made available to conduct these automated matches. States will receive the normal 50 percent match for administrative expenses related to implementation of the new law. The law also requires that the Secretary develop an outreach program which is intended to educate individuals who are likely to be affected by the requirements of this provision of the law. CMS has already conducted numerous teleconferences with states and other organizations interested in this provision. In addition, we are developing an outreach plan that provides strategic direction and coordination for an integrated education and outreach program to inform states, Medicaid recipients, and others of these new documentation requirements. This initiative will be implemented to promote active and informed involvement by states and people with Medicaid in providing beneficiaries the necessary information about the new documentation requirements. The plan will ensure that all stakeholders know of the new requirements, understand the documents which satisfy these requirements, assist the streamlined implementation by states, and ensure continued uninterrupted access to Medicaid for citizens. EMTALA Regarding the broader health care system, CMS enforces the 1986 Emergency Medical Treatment and Labor Act (EMTALA). Under EMTALA, hospitals have obligations to any individual, regardless of citizenship, who requests treatment for a medical condition. EMTALA was designed to ensure that people will receive appropriate screening and emergency treatment regardless of their ability to pay. CMS’ regulations implementing EMTALA require that hospitals with dedicated emergency departments provide an appropriate medical screening examination to any person who comes to the hospital emergency department and requests treatment or examination of a medical condition. They also require that these hospitals provide an appropriate medical screening examination to any person who presents himself on hospital property requesting evaluation or treatment of an emergency medical condition. In both cases, a request may be made by another individual on behalf of the person for whom examination or treatment is sought, or a request can be considered to have been made if a prudent layperson believes that based on the behavior of the individual an emergency medical condition exists. If the examination reveals an emergency medical condition, the hospital must also provide either necessary stabilizing treatment or arrange for an appropriate transfer to another medical facility. EMTALA applies to all Medicare-participating hospitals with dedicated emergency departments and applies to all individuals regardless of immigration status who present themselves requesting examination or treatment of a medical condition. Hospitals with specialized capabilities have a responsibility under EMTALA to accept appropriate transfers regardless of whether the hospital has a dedicated emergency department. A hospital that violates EMTALA may have its ability to participate in Medicare terminated and may be subject to civil penalties of up to $50,000 per violation. An individual who has suffered personal harm and any hospital to which a patient has been improperly transferred and that has suffered a financial loss as a result of the transfer are also provided a private right of action against a hospital that violates EMTALA. Hospitals also are required to maintain lists of physicians who are on call for duty after the initial examination to provide necessary stabilizing treatment. Hospitals have discretion to develop their on-call lists in a way that best meets the needs of their patients requiring services required under EMTALA. Under CMS’ regulations, EMTALA does not apply after an individual has been admitted for inpatient hospital services, as long as the admission is made in good faith and not in an attempt to avoid the EMTALA requirements. Section 945 of the MMA required the Secretary of Health and Human Services to establish a technical advisory group (TAG) to review EMTALA policy, including the regulations and interpretive guidance outlining hospitals’ responsibilities under EMTALA. This TAG, which includes hospital, physician and patient representatives, has already met 4 times. The TAG will complete its deliberations and submit a report of its findings and recommendations to the Secretary by October 2008. Conclusion Thank you again for this opportunity to discuss the impact of undocumented immigrants on Medicaid and the health care system. I would also like to take this opportunity to once again express the Administration’s support for comprehensive immigration reform. I would be happy to answer any questions you might have.
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