This study conducted by the California Endowment and the California HealthCare Foundation found that the new federal requirement to conduct citizenship checks on all Medicaid applicants has added considerable costs to all 58 California counties.  The study also found that the citizenship checks created new barriers to care for qualified applicants and yielded few cases of fraud.

From the report:

The federal statute and implementing regulations promulgated by the Centers for Medicare and Medicaid Services (CMS) are very specific and define a limited and prescriptive list of documentation that can be used to satisfy the DRA requirement, including a hierarchy of acceptable documentation. When acceptable documentation is not immediately available, federal guidance directs the states to provide a “reasonable opportunity period” (ROP) for applicants and enrollees to present the necessary documentation. California’s Department of Health Care Services (DHCS) moved in a deliberative manner to implement the new requirement. Acting specifically to minimize any potential negative impacts of the DRA, DHCS completed several data matches of current Medi-Cal eligibility files and California Vital Statistics data prior to issuing guidance to the counties. DHCS also updated the Medi-Cal Eligibility Data System (MEDS) to allow county eligibility workers to request birth matches for Medi-Cal clients. DHCS issued All County Welfare Directors Letter (ACWDL) Number 07-12 on June 4, 2007 directing the counties to begin to operationalize the DRA requirement. However, even with the measured pace of implementation in California, concern remained about the potential negative impacts of the DRA requirement on Medi-Cal clients and California’s counties.

Full report: Impact of the DRA Citizenship and Identity Documentation Requirement on Medi-Cal: Findings from Site Visits to Six Counties (PDF | 145.34 KB)

The California Endowment. (2009). Impact of the DRA citizenship and identity documentation requirement on Medi-Cal: findings from site visits to six counties. Davis, C., Brown, G., Smith, V., Ellis, E. and Hughes, D.