There has been a lot of information and misinformation about Medicaid coverage for immigrants circulating in the news, including wildly inaccurate reporting that undocumented immigrants are driving up Medicaid spending—when the truth is that they are NOT even eligible for traditional Medicaid. At the same time, while some Republicans in Congress have said they are only going after undocumented people and fraud, House Republicans just made a major change to their proposed legislation specifically targeting children and pregnant women who are here legally and properly enrolled. Let’s cover some basic facts about who is and isn’t eligible for Medicaid under current law, and the harmful changes being proposed in the bill. (Note: The Congressional Budget Office now estimates the bill will cut about $800 billion in Medicaid, and has previously estimated over 8 million people will lose Medicaid coverage.)
Undocumented immigrants are not eligible for traditional Medicaid – nor are many legal immigrants for that matter.
In order to be eligible for traditional Medicaid coverage, individuals who are not U.S. citizens (by birth or naturalization) must have a “qualified” immigration status. Qualified status is a complex topic which requires immigration law expertise; it includes legal permanent residents, refugees, asylees, and several other groups. Undocumented immigrants are not in a “qualified” status and thus are not eligible. In fact, many immigrants that are in a legal status are also ineligible because they are not on the “qualified” list. For example, individuals on student visas, tourist visas, business visas, exchange visitors, and Deferred Action for Childhood Arrivals (DACA), can all be in a perfectly legal status but are generally not “qualified” and therefore ineligible for traditional Medicaid. The “qualified” immigrants eligible for traditional Medicaid can be thought of as a subset of the legal immigrants in the country.
Even qualified immigrants are not always eligible for traditional Medicaid.
Although individuals need a qualified status to be eligible for traditional Medicaid, some qualified immigrants are not immediately eligible for enrollment. This is because individuals in some qualified statuses are subject to a five-year waiting period (sometimes referred to as “the five year bar”) before their coverage can begin. Such individuals must wait five years from the date they get their qualified status before they can enroll in Medicaid. Some qualified statuses are generally subject to the five-year waiting period (for example, legal permanent residents), while others are not (such as refugees).
States have the option to waive the five-year waiting period for legal immigrant children and pregnant women.
Under Medicaid law, states have the option to waive the five-year waiting period (described above) for immigrant children and pregnant women. Known as the ICHIA or CHIPRA 214 option, states may provide coverage to any children and/or pregnant women that are in a legal status (unless specifically excluded, such as DACA grantees). Per KFF data, thirty-eight states currently do this for children, and thirty-two for pregnant women. The option was created in the Children’s Health Insurance Program (CHIP) Reauthorization Act of 2009 (CHIPRA) and its widespread adoption across states and across the political spectrum indicates strong bipartisan support for these options among the states.
Hospitals and other providers can get Medicaid reimbursement for emergency care provided to all individuals who meet Medicaid income limits, regardless of immigration status.
Under federal law, hospital emergency departments must screen, treat, and stabilize anyone who presents with an emergency medical condition (see section (e)(1) of the federal law for exact definition), regardless of insurance status. Under “Emergency Medicaid,” hospitals can be reimbursed by Medicaid for emergency care provided to an individual who would be eligible for Medicaid coverage of the care, but for their immigration status. This reimbursement can include payment for services rendered to stabilize undocumented immigrants. About half of this funding is used by hospitals as reimbursement for labor and delivery services for the birth of U.S. citizens. Emergency Medicaid funding is critical to the finances of hospitals and critical to healthy birth outcomes for U.S. citizen babies. The reimbursement covers only treatment related to the emergency medical condition, and is unlike Medicaid coverage in that it is extremely short-term (often lasting just one day) and covers only a sliver of the Medicaid benefits package – acute care related to the emergency medical conditions (and not prevention, chronic care, etc.). Note that individuals qualifying for Emergency Medicaid must meet all other Medicaid requirements that apply to U.S. citizens – such as income limits, asset tests, and other eligibility criteria. Practically, this means that no undocumented immigrant can qualify for emergency services that a similarly situated U.S. citizen would not already qualify for.
This emergency funding is the only type of Medicaid spending on undocumented immigrants, is a very small part of Medicaid spending (less than half of one percent of spending), and the current House legislation does not propose to make any changes to this coverage.
State-funded expansions to immigrants are not Medicaid.
About 14 states and DC provide some form of coverage to some immigrants, usually children, regardless of immigration status using only state dollars. These state programs do not use federal Medicaid dollars, are not subject to Medicaid standards and requirements, and are not, by definition, Medicaid.
House Republican proposals target cuts for state-funded coverage, and now, legal immigrant children and pregnant women too.
The most harmful (and likely unlawful) provision targeting immigrants in the House Republican proposal is one in which the federal government would strip some states of federal funding based on how states spend their own state dollars. Under current law, the Federal Medical Assistance Percentage (FMAP) for Medicaid expansion is 90% – meaning the federal government ultimately pays for 90% of the cost of Medicaid services, with states paying 10%. The House Republican bill (in its original form) would penalize states that use state dollars to provide coverage for undocumented immigrants, by reducing their Medicaid expansion FMAP to 80%. This would be a gigantic Medicaid cut in those states and double the cost of Medicaid expansion for those states. As described above, 14 states and DC currently offer such coverage outside of their Medicaid programs and the coverage most often goes to children and pregnant women who will give birth to U.S. citizens. Despite the strong policy reasons for the states to preserve the coverage, states would be under enormous financial pressure to cancel their own state programs. There is no legal authority for the federal government to withhold Medicaid funding to a state based on things it does outside of its Medicaid program.
Most recently, the House Republican bill was made even more harmful by expanding the penalty to also penalize states that provide coverage to legal immigrants. This revised version of the bill would specifically target states providing coverage to children and pregnant women who are legal immigrants under the ICHIA option described above. These states would effectively be forced to abandon their ICHIA coverage, or else face the gargantuan Medicaid expansion penalty. The House Republican bill thus represents an attempt to largely end bipartisan ICHIA coverage for children and pregnant women through a back-door trick.
However, at the same time, the bill is designed to favor some states over others, because the penalty only applies to states that have expanded Medicaid. So for example, North Carolina and Florida both currently use ICHIA to expand coverage to legal immigrant children, however, only North Carolina will face a crushing loss of funding for doing so, while Florida will suffer no consequence at all.