A canary in the coal mine: Documenting citizenship and identity in the State of Massachusetts

Objectives: The U.S. federal government requires original documentation of citizenship and identity for applicants to qualify for coverage under Medicaid. The purpose of this investigation is to identify what challenges one state Medicaid agency has faced when implementing this requirement; and to identify what strategies this agency and other interested parties (e.g., providers, community advocates) adopted to help overcome them. Methods: The setting for this study is MassHealth, the Medicaid agency for the State of Massachusetts. Data derive from archival documents, direct observation, and in-depth interviews with key stakeholders, including state officials, provider agencies, community health centers, and beneficiary advocates. Results: While MassHealth has met several of the implementation benchmarks put forth in federal regulations and guidance letters, the agency has fallen short in several respects. This includes assisting applicants seeking to enroll in MassHealth and maintaining a seamless documentation submission process. The result has been an increase in application processing time and misinterpretations in the MassHealth community; for example, that legal immigrants should not apply for coverage even though the new requirement does not affect them. Assuming a prominent role in informing and assisting MassHealth applicants has been providers and community-based organizations. Consumer advocacy groups have also worked to streamline the process for demonstrating citizenship and identity. Synergies have been formed between MassHealth and these other organizations as well. Conclusions: Findings suggest a number of lessons for state Medicaid agencies wishing to address the challenges posed by federal requirements to demonstrate citizenship and identity. These include working to ensure the readability, comprehension and non-English translation of materials provided to program applicants. It also includes strengthening the document handling process and forming partnerships with providers, beneficiary advocates, and other community organizations.