A Medicaid rule takes effect tomorrow that will require more than 50 million poor Americans to prove their citizenship or lose their medical benefits or long-term care.

Under the rule, intended to curb fraud by illegal immigrants, such proof as a passport or a birth certificate must be offered at the time a person applies for Medicaid benefits or during annual reenrollment in the state-federal program for the poor and disabled.

Critics fear that the provision will have the unintended consequence of harming several million U.S. citizens who, for a variety of reasons, will not be able to produce the necessary paperwork. They include mentally ill, mentally retarded and homeless people, as well as elderly men and women, especially African Americans born in an era when hospitals in the rural South barred black women from their maternity wards.

"My clients are absolutely dependent on Medicaid for their care," said Andrea Sloan, a lawyer and court-appointed guardian for more than 40 District residents. Many suffer from dementia, lack family contacts and have little in the way of paper trails. Although Sloan is convinced of their citizenship, she is not always sure of such details as their birthplace.

The new provision is part of last year's Deficit Reduction Act, which President Bush signed into law in February. Despite a federal inspector general's report concluding that there was little fraud by noncitizens, supporters said the measure would ensure that Medicaid dollars go only to citizens or eligible immigrants.
Rep. Charles Whitlow Norwood Jr. (R-Ga.), one of the prime sponsors, decried "the outright theft of Medicaid benefits by illegal aliens."

A lawsuit filed in federal court in the District yesterday contests the new rule's constitutionality and seeks to prevent its implementation in the city, where more than 140,000 residents receive Medicaid. "The rule's going to exclude citizens and deny them rights that citizens are entitled to," said Clifton Elgartenm, a lawyer with Crowell & Moring, which is working pro bono and sued the District on behalf of the nonprofit social services organization Bread for the City and individual plaintiffs.

One plaintiff is Alphonso DeShields, who was born in his parents' home in Spartanburg, S.C., a few months after World War I began. For five years, he has lived in a nursing home in Northwest Washington. He has a severe heart condition, cancer and other ailments.

"With respect to each of the documents" Medicaid would have him supply, the lawsuit states, "Alphonso DeShields possesses neither an original of such a document nor a copy of such a document certified by the original issuing agency."

District officials, like their counterparts in the states, have no choice but to comply; otherwise, federal Medicaid funds would be withheld. About $900 million would be at stake in the District alone.

Robert Maruca, head of the D.C. Medical Assistance Administration, said yesterday that he expects that many residents with a right to Medicaid will be unable to demonstrate their citizenship.

"I'm afraid they may be dropped out of the program," he said.

On Wednesday, a lawsuit challenging the Medicaid rule was filed in Chicago by a coalition of advocacy groups that wants the suit certified as a national class action. "In the process of pandering on the illegal immigrant issue, members of Congress will do enormous harm to the American citizens who need help the most," Ron Pollack, executive director of Families USA, said during a teleconference.

Among the plaintiffs in that case are Ruby Bell, 95, born in an Arkansas county that did not issue birth certificates until 1914, and George Crawford, 80, who is so incapacitated from strokes that he cannot speak. According to attorneys, the church members who care for Crawford in Illinois don't even know where to start looking for documents that would pass muster.

Until now, Medicaid recipients have declared their citizenship, under penalty of perjury, without having to show evidence of it. States have been able to demand substantiation in suspicious cases. No longer will that process suffice.

New applicants will be affected immediately and will be denied benefits until they offer proof of citizenship. Current recipients will not have to back up their declarations until their first annual reenrollment, when they will have 45 to 90 days to do so, depending on their circumstances.

Medicaid spokeswoman Mary Kahn said the federal Centers for Medicare and Medicaid Services had made "every concerted effort to ensure [the requirement is] not overly burdensome on beneficiaries." She declined to comment on the litigation.

In a June 9 memo to states, federal officials announced a hierarchy of documents that would be acceptable. Virtually all must be accompanied by a driver's license or something else establishing a person's identity -- another obstacle for young and old alike, critics stress. Medical, insurance or census records can be used under specific conditions. Entries in family Bibles don't qualify.

The provision "throws out a dragnet and says, 'All of you, all 50 million of you, need to come in here and document your citizenship whether we think there's a problem or not,' " said John Bouman, a lawyer with the Sargent Shriver National Center on Poverty Law.

On Capitol Hill yesterday, several members of Congress called for a delay in implementation. They said verification will effectively bar some Medicaid recipients from health care. Just how many is unclear. The Congressional Budget Office estimated that the requirement would cause 35,000 people, mostly illegal immigrants, to lose coverage by 2015 and lower Medicaid spending by $735 million over 10 years.

But the Kaiser Commission on Medicaid and the Uninsured has warned that the benefits of many citizens will be delayed or denied. Cindy Mann, director of the Center for Children and Family at Georgetown University's Health Policy Institute, suggested that at least 3 million citizens could be stripped of coverage.

"We are risking people's health care," she said. "And it is a lot of paperwork to solve a problem no one identified."

For the states, administrative costs will be considerable. Maryland and Virginia each have more than 700,000 Medicaid enrollees.

"We've been working pretty feverishly to try and figure out what this means," said Charles Lehman, director of medical care programs for the Maryland Department of Health and Mental Hygiene.

Stephanie Sivert, manager of Virginia's medical assistance program, said clients who are mentally disabled or homeless, living in institutional settings, often have made a complete break with their pasts.

"It's not going to be easy for them to access these records," she said.