By Dinah Wiley
In Part I of this blog series, I noted that immigrants have unique concerns about signing up for health insurance, and are less likely than citizens to do so, and that blog addressed confidentiality concerns of immigrant families.
The privacy concerns are paramount, yet a mixed-status family will also wonder if they can successfully show immigration status, meet requirements for Social Security or other tax identification numbers, prove income and identity, and demonstrate state residency. Other verification concerns involve the state agency’s procedures: what if there is a discrepancy between what the family says on the application and what other evidence seems to show? What if there is a delay in confirming eligibility?
Verification Rules and Procedures
In this blog, I will focus on verification rules and procedures, which have presented sometimes insurmountable barriers to immigrants in the past. And even with ACA-related improvements, verification of immigration status can be especially complicated for some who are lawfully present but lack green card (Lawful Permanent Residence or “LPR”) status or an Alien Number (“A#”). Looking at the list of lawfully present immigration categories it becomes apparent that LPR is only the first category on a long list of statuses that confer eligibility. Immigrants who lack a green card may scroll further down that list to see a dizzying array of alternative documents that show lawful presence. The expansive definition of lawful presence and the evidence list posted on the healthcare.gov website, will hopefully be a great help to families looking for information about how to verify immigration status.
In addition, HHS has proposed to apply a well-established, helpful Medicaid rule to CHIP and the new marketplaces: during the time it may take for the Department of Homeland Security (DHS) to verify an applicant’s immigration status, agencies are prohibited from delaying, denying, reducing or terminating coverage or marketplace subsidies. This helps individuals who encounter delays in navigating the DHS system for verifying health care and other safety net eligibility. The system, known as “SAVE”—Systematic Alien Verification for Entitlements, sometimes cannot quickly confirm an individual’s immigration status. And some lawfully present categories can be complicated to verify, a few examples are holders of “U” visas and “T” visas — survivors of various crimes who may have been brought to the U.S. against their will and may have urgent needs for medical care. Providing medical coverage pending confirmation of status can help ensure that verification delays don’t endanger health.
When individuals apply for coverage on-line, initial attempts at verification are electronic, through the Federal Data Services Hub (“hub”). The ACA envisions almost-instantaneous verification of most information on a health insurance application through the hub. If there are delays in confirming non-financial information (such as immigration status), the rules require that the applicant be given a “reasonable opportunity” to establish eligibility or resolve an inconsistency by showing documentation. The time period for this reasonable opportunity is proposed as 90 days, across all programs.
Aside from proving eligible immigration status, which as we’ve seen has become a little easier as a result of health reform, immigrant families have additional verification concerns. How will they prove identity and income if they can provide only a non-traditional ID, such as a foreign passport, or a non-work Social Security number or employer’s letter in lieu of a pay stub? Many worry that without their own SSN, they may not be able to apply for others in their family who are eligible for coverage.
Barriers Causes by Social Security Requirements
A number of rules address barriers caused by SSN requirements. SSNs are important to ACA enrollment; they are the primary gateway to the hub and facilitate income verification for those applying for help with costs. Through the SSN, citizenship can be quickly verified through the Social Security Administration (SSA), and the previous year’s tax-filing income amount can be confirmed electronically by the Internal Revenue Service (IRS).
In the past, safety net applications have included unnecessary requirements for SSNs, deterring immigrant families from participating. New regulations seek to remedy this by prohibiting state agencies from requiring non-applicants to provide SSNs. This means that generally, an ineligible family member who is not applying for herself and does not have a SSN can apply for eligible individuals in the household. There is one exception: a non-applicant must provide a SSN if he or she does have one, if he or she is the tax-filer, and if he or she is applying for help with the costs of coverage. And even when the agency cannot require a SSN, it may request one. (Under the 1974 Privacy Act, when an agency requests the SSN of a non-applicant, the agency must advise the non-applicant that the SSN is optional, provide the non-applicant with notice of the authority for the SSN request, and provide information about how the SSN will be used.)
Under new ACA rules, eligible family members who are applicants must provide SSNs only if they have one. The “if” is important: there is no longer an absolute requirement to provide a SSN. The agency must help an applicant obtain a SSN who is eligible but who has not yet applied for the SSN. As a further twist, some lawfully present immigrants may be eligible for health insurance but not be eligible for a SSN (such as some Cuban or Haitian Entrants, some applicants for Special Immigrant Juvenile Status, and others). The SSA is authorized to issue a “non-work SSN” when a SSN is required for enrollment in a government program. Because this is a little known rule, however, even among agency workers, immigrants sometimes get the run-around between the state agency and SSA. A new Medicaid rule under health reform permits states to assign a unique identifier number as a proxy for the SSN. States can be encouraged to take advantage of this opportunity to facilitate enrollment.
When presented with a request for their SSN, individuals should provide only SSNs issued to them by SSA. They should not provide Individual Tax Identification Numbers (ITINs), a number that has nine digits like the SSN but is issued by IRS for tax-filing purposes. If an individual does not have a SSN, they should leave the question blank. But application assisters should be aware that people lacking SSNs still can and do file tax returns. ITIN filers can make a point of saving a copy of their previous year’s return as useful evidence of income when applying for help with costs of coverage.
Immigrant Families Need Flexibility
With verification of income, identity, state residency, and other eligibility factors, regulations recognize that the key to removing barriers for immigrant families is flexibility. Agencies need to recognize that an electronic record of employment, or even a pay stub, may not exist, but other evidence will be available. Application filers may now attest to the income of their family or household; documentation is required only if needed to resolve an inconsistency. Foreign passports and a range of other documents may now be presented if needed to establish identity. And a new regulation prohibits agencies from drawing conclusions about state residency based on an individual’s immigration status. This corrects a past practice of barring immigrants from coverage who have visas that appear to be temporary in nature.
The next blog will address other barriers to enrollment of immigrant families, such as confusion about eligibility, concerns that an application for help with costs of health insurance will affect the ability to receive a green card, concerns about sponsors, and the importance of rolling out the welcome mat by infusing the entire enrollment process with hospitality to immigrants and their families.
