Enrollment in the RIte Care program has shrunk by nearly 6,000 in the past year, and advocates say they are concerned that a change in federal policy is causing the poorest of the poor to lose their state-subsidized health coverage.

Among families earning less than the federal poverty level — $17,170 a year for a family of three — enrollment dropped by more than 4,000 people, according to Rhode Island Kids Count, which gets regular updates on enrollment figures from the state Department of Human Services.

“That’s the core population that RIte Care is intended to reach,” says Jill Beckwith, a policy analyst with Kids Count.

The bulk of the enrollment drop also came in the last six months. Since January, the program has seen a net loss of 4,852 members, said Lisa Franchetti, a membership analyst with Neighborhood Health Plan of Rhode Island, whose plans cover about 60 percent of RIte Care subscribers.

Since January 2005, RIte Care enrollment has fallen from 119,000 to 111,000, but the drop in the last six months is “unprecedented,” says Neighborhood Health Plan spokesman Tom Boucher.

Boucher, Franchetti and Beckwith say the federal Deficit Reduction Act is responsible. The bill, passed by Congress last year, contained a variety of measures, including stricter requirements for documentation and proof of identity for people receiving government-subsidized health insurance. The stricter standards have applied to all new enrollments since January.

People now need an official copy of their birth certificate, which costs $20 in Rhode Island and can cost substantially more if ordered by mail from another state.

Beckwith noted that she paid $75 to the State of New York for a copy of her own birth certificate before a recent trip to Mexico. For a family of three making $17,000 a year or less, that’s a significant burden, she said.

New enrollees also need four pay stubs to substantiate the income level they are claiming.

Each of the requirements is “another piece of paper that has to be in someone’s file before eligibility can be determined, and another reason for denying them if they fail to get that piece of paper in there,” says Linda Katz, policy director for the Poverty Institute at Rhode Island College.

Although the changes do not yet affect renewal cases, they are having an impact on some people who are already covered by RIte Care because if coverage ends for even a single day, the case is considered a new enrollment.

People who miss a deadline to return paperwork or miss an appointment with a case worker can have their benefits terminated, if they try to sign up a week later, they find a new set of bureaucratic hoops to jump through to get their coverage reinstated. Suddenly, they need to visit a state office instead of simply mailing in a renewal form, and they need additional documents they didn’t have to provide a year ago.

Those who defend the new requirements say they will reduce abuse and fraud in benefit programs. But the group losing coverage, says Katz, “is not people who are not citizens. It’s people who can’t afford to get the documents they need to present.”

Advocates say the bigger impact will come in November, when the stricter documentation standards take effect for renewals, as well as new enrollments.

“We’ve been trying to flood our membership” with information about the new requirements, says Franchetti, who coordinates Neighborhood Health Plan’s out-reach efforts on the requirements.

The insurer has put the information in newsletters and on postcards. Reminder telephone calls have been made to members. When someone calls in to the insurer, the people answering the phone make a point of mentioning it. Even the recorded message callers hear when they’re placed on hold offers information about citizenship and identity verification.

Advocates are also trying to get the policy change reversed. Both houses of Congress have passed bills aimed at extending and expanding the State Children’s Health Insurance Program, which provides part of the money for RIte Care and its counterparts in other states. The bills are headed for conference committee, where lawmakers will work to reconcile the differences after Congress returns from its August recess this week.

Both versions contain provisions that would mitigate the Deficit Reduction Act requirements. The House bill would allow states to return to the previous rules for proving children’s citizenship — in other words, birth certificates would not be required. The Senate bill would allow states to accept a Social Security number to verify identity and citizenship, provided the state verifies the number with the federal government.

Katz says the increased documentation requirements, combined with increased public skepticism of the recipients of public benefits, only add to the stigma that surrounds receiving those benefits.

When the state launched RIte Care in 1994, Katz says, “there was a sense in the community and the state that coming onto RIte Care was a good thing to do,” because it meant getting access to preventive care and avoiding costly emergency visits later on.

In recent years, however, “there’s been a real denigration of public benefits, including RIte Care,” she says. “I think that stigma … discourages people from coming through the door. … We need to open the door again so people can get through easily.”

egudrais@projo.com