Even close followers of Congress and the Administration may have missed a couple of recent developments about access to health coverage for Afghan evacuees arriving in the US following the withdrawal of troops this summer. The complexity of immigration rules and Medicaid eligibility rules has led to a lot of confusion about Medicaid eligibility specifically, but thankfully, recent actions by Congress and the Administration have cleared things up.
Generally speaking, refugees are eligible for Medicaid coverage without a 5-year waiting period. However, immigration statuses are complex, and many Afghan evacuees are technically considered special immigrant visa holders or humanitarian parolees. While both of these groups are considered lawfully present, the Medicaid eligibility rules differ by group.
Afghan special immigrant visa holders were granted refugee-like Medicaid eligibility back in 2009 (P.L. 111-8 Section 602(b)(8)). However, until recently, humanitarian parolees who are paroled for a year or more (most Afghans in this group are expected to be paroled for 2 years) would have been subject to the 5-year bar. (Humanitarian parole is the legal process used to evacuate someone and bring them to the United States due to a humanitarian emergency and should not be confused with parole from prison.)
At the end of September, Congress expanded access to coverage for Afghan evacuees as part of the Continuing Resolution (CR) to fund the government (P.L. 117-43 Section 2502). The CR gives Afghan humanitarian parolees paroled on or after July 31, 2021 access to the same benefits as refugees, meaning the 5-year bar does not apply.
Just before the CR passed, CMS issued guidance to help states and advocacy organization understand the health coverage options available to Afghan evacuees, and earlier this week, CMS updated this its guidance reflecting the new rules as laid out in the CR.
As a result, Afghans who enter the US as either special immigrant visa holders or humanitarian parolees are eligible for Medicaid or CHIP without a 5-year waiting period, as long as they meet the other eligibility requirements (e.g., income) for coverage in the state. Afghan special immigrant visa holders are eligible for Medicaid/CHIP for the same time period as refugees, typically seven years. While the CR granted Afghan humanitarian parolees the same access to Medicaid/CHIP as refugees, this eligibility only lasts until March 31, 2023, or the term of parole granted to the evacuee, whichever is later. Afghans who are ineligible for Medicaid or CHIP may be eligible for Refugee Medical Assistance (RMA, limited to only 8 months) or Marketplace coverage with financial assistance.
Enrollment in Medicaid/CHIP is open year round. Importantly, the CMS guidance makes clear that even if states are unable to verify an Afghan evacuee’s immigration status promptly, states are required to furnish benefits to Afghan evacuees who attest to having an eligible immigration status for a 90-day reasonable opportunity period while good faith efforts are made to verify immigration status.
Marketplace enrollment is typically limited to an annual open enrollment period (November 1, 2021 – January 15, 2022). However, Afghan evacuees may enroll in Marketplace coverage within 60 days of arrival or loss of coverage through Medicaid, CHIP or RMA (even if the open enrollment period has ended).
Though California and Texas are expected to receive the largest number of Afghan evacuees, nearly every state will become home to at least some Afghan evacuees. Experts at State Health and Value Strategies (SHVS) and Manatt Health outlined some state strategies to enroll Afghan evacuees in health coverage, including: training assisters and navigators about Afghan evacuees’ eligibility; out-stationing Medicaid eligibility workers to facilitate enrollment at hospitals and clinics; and using presumptive eligibility, including adding military bases or medical hotels where Afghan evacuees are housed as qualified entities, to process applications quickly. Additionally, SHVS and Manatt recommend that states take a multi-pronged and proactive approach to maintaining contact with Afghan evacuees by partnering with trusted, community-based organizations; creating specialized notices in Pashto and Dari; and encouraging applicants to use stable mailing addresses such as a local service agency as they get settled.
There has been strong, bipartisan support for welcoming Afghans and states now have the opportunity to channel that energy to connecting Afghan evacuees to needed health coverage.