Melissa Monteiro says she and her seven-month-old son were both born here in Rhode Island, at Women & Infants Hospital. So there’s a little doubt that they’re citizens.

And since Monteiro, 18, doesn’t have a job, there is also little doubt that she and her son qualify for coverage under the state’s RIte Care health plan for the poor.

But Monteiro, who lives in Pawtucket, hasn’t been able to enroll. She had trouble locating the documents needed under new federal rules to prove that she and her baby are American citizens.

When her baby spiked a fever recently, she took him to a hospital emergency room. And later when he got a bad cold, she took him to the Blackstone Valley Community Health Center. Both places took care of him. But Monteiro says she has no ability or intention to pay the bills the hospital has been sending her.

Monteiro’s predicament is typical of what’s happening as the state slowly starts enforcing a federal law setting new documentation requirements for anyone enrolling or re-enrolling in the Medicaid health program for the poor, which RIte Care is part of. In the past, people merely had to declare that they are citizens. Now they have to prove it, usually with birth certificates, and also prove that they are who they say they are, usually with driver’s licenses.

Governor Carcieri’s budget proposal expects to save nearly $20 million by removing from RIte Care some 5,700 people who will not be able to meet the new requirements.

But state officials say they never believed that anywhere near 5,700 noncitizens have been illegally obtaining health care from the state.

Instead, the vast majority of those who will be cut from RIte Care are people like Monteiro — citizens who are entitled to coverage but couldn’t get the documents.

“It’s really hurting U.S. citizens. This is actually hurting eligible people,” said Brenda Whittle, director of marketing and external affairs of Neighborhood Health Plan of Rhode Island, an HMO serving RIte Care enrollees. “The problem is, they’re going to get health care. They’re just going to get it when it’s really, really, really expensive.”

Monteiro, who’d faced delays getting her son’s Social Security number, says she’s finally submitted their documents and hopes that eventually she will be enrolled in RIte Care. But her application is still being processed — and that process is moving slowly. The state Department of Human Services and health clinics around the state have had to handle the additional administrative burdens without additional staff.

Meanwhile, Monteiro’s loss of coverage may have already cost the system. Her visit to the emergency room was significantly more expensive than a visit to doctor’s office. And the bill for the care could become part of the growing burden of free care that hospitals around the state say is pushing them into deficits.

Gary Alexander, acting director of the state Department of Human Services, said that between Jan. 20 and the end of March, 458 people were denied enrollment in RIte Care for failure to provide documentation. But some of them may eventually qualify.

“We realize that this is a burden and we want to make sure that our citizens have access to our programs,” Alexander said.

John Young, Medicaid director, said the state estimated an eventual loss of 5,700 people based on the experiences in other states that moved faster in implementing the federal requirements. The number represents about 5 percent of the RIte Care rolls.

“We don’t see anything that says that we have thousands or even hundreds” of illegal immigrants participating in RIte Care, Young said.

Young said the state is moving slowly in implementing the law and trying to help people as much as possible. The state didn’t begin asking for documents until mid-January, and it applied the rule only to people who were applying for the first time or reapplying after leaving the program. Starting April 1, the documents are also being required of people already on RIte Care who are undergoing their twice-yearly recertification. Those people have 90 days to come up with the documentation before they will lose their coverage.

By all accounts, the documentation requirements are daunting.

Tony Lopes, a family resource counselor at Blackstone Valley Community Health Center, said many people applying for RIte Care cannot afford the $15 cost of getting each birth certificate.

“A mom with three or four kids, sometimes a single mom, making $200 a week — where are they going to come up with the money? I never thought RIte Care was going to go this far,” Lopes said.

“Imagine your child was born in Queens!,” said Tom Boucher, spokesman for the Neighborhood Health Plan. “The Medicaid audience reads at a fifth-grade level.”

Added Whittle, Neighborhood’s marketing director: “Particularly people who live in the city — they don’t have driver’s licenses. They don’t necessarily have cars. It’s not only a financial expense but it’s also taking an afternoon off of work.”

The state has deputized workers who take RIte Care applications at the community health centers, hospital clinics and elsewhere to ascertain that birth certificates are originals with a raised seal; then copies can be faxed to DHS.

Additionally, the state has allocated $250,000 for a system that will connect the Health Department’s vital records with DHS, speeding the processing of applications. But the system won’t be operating for at least two months. And it won’t help people who were born out of state.

Kerrie Jones Clark, executive director of the Rhode Island Health Center Association, said the documentation requirements will have “huge” effect on the health centers, because it will increase the number of uninsured people, who typically pay for only 20 percent of the cost of their care at health centers.

“What the law is really doing is really undermining the financial viability of the health centers,” Clark said.

Confounding the situation is the fact that RIte Care has been seeing a steady — and unexplained — decline in enrollment that became surprisingly steep in January and February of this year. RIte Care enrollment was at 112,636 at the end of February, down by more than 5,000 from the same time last year.

Advocates for the poor were blaming the new documentation rules for the program’s losing 3,400 people this year, but Medicaid officials said it was impossible for the rules to have had that effect so quickly.

Alexander, the DHS director, says he’s not ready to denounce the documentation rules. He said that the U.S. Government Accountability Office was assessing their effects. “I don’t want to say that this is not a good thing until it’s studied in its full effect,” he said.

ffreyer@projo.com