By Dinah Wiley

Immigrant families are among the most in need of health reform, with high rates of uninsurance and poverty despite employment rates as high as those of citizen-headed households.  How will these families fare under health reform?  Though a few federal rules are still undecided, we can safely say that many non-citizens will find a new pathway to coverage after October 1, thanks to the ACA.

In this blog, the first of a series about health coverage and care for non-citizens, we’ll explain the eligibility differences across major programs.  Future blogs will address access barriers for the eligible but uninsured, and the health care landscape for those who are not eligible.  Imagine some or all of those eligibility scenarios existing under one roof – an undocumented Mom and Son, a Lawful Permanent Resident (LPR) Dad, a citizen baby Daughter.  And maybe the family includes a young Uncle who is an asylum-seeker fleeing persecution in his home country?  Such “mixed-status” immigrant families are the majority of America’s immigrant families.  Who gets coverage?

We begin by stating the obvious, often overlooked fact:  baby Daughter’s eligibility is the same as that of any other citizen child in America.  Almost 90% of children living with immigrant parents are citizens.  Citizens in immigrant households are eligible for all programs to the same extent as citizens in native-born households, no difference.  It’s important to facilitate ALL citizens’ full participation in the best health care option for which they are otherwise eligible, regardless of the immigration status of other family members.  This is just as true for foreign-born family members who through naturalization have now become citizens.

Second, immigrant families will often include a non-citizen who has documentation, like Dad with his LPR green card.  For these family members, the eligibility rules will depend on which documented immigration status the individual has.  If the family is income-eligible for Medicaid or CHIP in their state, then generally non-citizens must have a “qualified immigrant” status, like LPR and other statuses defined as “qualified,” and be unencumbered by the five-year waiting period imposed on newcomers.  Uncle’s application for asylum, if still in process, would not confer “qualified immigrant” eligibility for these public programs.  But he will be eligible after his application is approved and he becomes an “asylee.”

The above may sound familiar.  If so, it’s because federal immigrant rules for Medicaid and CHIP were not changed by the ACA.  Nor were the exceptions.  For example, humanitarian immigrants like Uncle, once he becomes an asylee, are exempt from the five year bar.  State options and variations matter too.  States may draw down federal dollars to cover kids and pregnant women, with no waiting period, in an expanded list of immigration statuses defined as “lawfully present.”   Almost half the states have made this important choice to cover more kids.  These are some, but not all, of the exceptions.

Just when our analysis seems complicated, it becomes easy when we turn to eligibility for the new health insurance marketplaces.  Under rules currently in place, it is the same list of “lawfully present” immigrants who will also be eligible for the ACA’s marketplace coverage and help with costs.  “Lawfully present” includes more immigration status categories, and thus brings more immigrants into the fold of health insurance eligibility, starting October 1.  Proposed regulations do change the “lawfully present” definition slightly, and HHS has not yet issued the final rule (stay tuned).

A few final tidbits:  Even immigrants who are income-eligible for Medicaid can apply for marketplace coverage and subsidies (in the event they do not otherwise meet strict Medicaid rules).  And on a final note, it’s good to remember that all families will need to file a tax return in the future to receive tax credits for eligible family members, and that tax filers without SSNs can file with an Individual Tax Identification Number (ITIN).

If this taste of the complex world of immigrant eligibility has tweaked your desire for a more complete picture, then look for future blogs on Say Ahhh! as well as a webinar presentation, September 26 at 1 pm ET, which will feature more specific coverage of immigrant eligibility and access rules, tips for overcoming barriers for these families, and a wealth of resource materials.