The Centers for Medicare and Medicaid Services would oversee the new rules. Mark McClellan, the agency's administrator, said he is sensitive to the concerns. He indicated that federal regulators are crafting a process for granting exceptions.

"We want to provide a reasonable amount of leeway," McClellan said. "Not everyone, at least in a timely way, can produce the statutory documents. We do expect that the vast majority of people will have little difficulty given enough time."

The policy change was approved in the February Deficit Reduction Act, which detailed $35 billion in spending cuts over five years, much of it from Medicaid. It came about when the inspector general for the U.S. Department of Health and Human Services found that a majority of states don't verify claims of U.S. citizenship by those seeking Medicaid benefits.

Nationwide yesterday, many health providers hoped federal officials would allow states to also accept documents such as voter registration cards, tribal documents, driver's licenses and military identification in lieu of a passport, birth certificate or naturalization certificate. They also asked that certain affidavits suffice as an alternative method of verification.

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For the past 15 years, California has generally required a Social Security number and signed declaration to become eligible for Medi-Cal. San Diego County also asks for a driver's license, proof of employment or school enrollment, receipt of public assistance, proof of voter registration and a rent or utility receipt.

The federal government's changes will cause an administrative nightmare for county processing agencies that ascertain Medi-Cal eligibility, several health experts said.

"What will happen is a huge delay," Lane said. "People will be jamming up with the application process."

It will be a difficult situation statewide, said Vicki Mizel, a deputy director for San Diego County's Health and Human Services Agency.

"When we start asking for documentation that up to now has never had to be provided, it will be a big problem," Mizel said. "I hope the advocates will work on this issue relentlessly."

One of those advocates, Greg Knoll, an attorney and director of San Diego's Consumer Center for Health Education and Advocacy, predicted such a "bureaucratic approach . . . will end up hurting possibly thousands of people who would otherwise be able to access health benefits."

He added that many immigrants who are here legally don't access health services they need "because they are afraid doing so will affect their legal status. And all this does is raise the fear level another notch."

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