Misinformation and confusion (even among lawmakers, more on that below) about immigrant eligibility and enrollment in Medicaid and CHIP (Children’s Health Insurance Program) continues to dominate the dialogue about the proposed changes in the House-passed reconciliation bill (see bill text as considered by the Rules Committee, alongside the manager’s amendment that was adopted before final passage). Admittedly, immigration rules are complex, as are Medicaid/CHIP rules, and the intersection of the two is compounding. We’ll try to clear things up.
Under current law, Medicaid and CHIP do not offer comprehensive coverage to undocumented immigrants, and in fact, many lawful immigrants also do not qualify. Even the lawfully present subset of immigrants who are “qualified” are generally subject to waiting periods. (For more details, see our recent blog on the basic rules of immigrant eligibility for Medicaid.) For noncitizens to be eligible for Medicaid and CHIP, they must meet all of the typical eligibility rules (e.g., categorically eligible as a child, pregnant woman, person with a disability, etc. and with income and assets below the applicable threshold) plus have a specified “qualified status” for a prescribed period of time. (See Figure 1.) As a result, many immigrants are not eligible for Medicaid. The lack of coverage options for immigrants leads to bad health and economic outcomes and raises serious concerns for children and pregnant women in particular.
Figure 1
| Medicaid Eligibility Requirements for Non-Citizens |
|---|
| Must fit in eligibility category (child, pregnant, senior, etc.) Meet income limits Meet asset limits (if applicable) Have a qualified immigration status; in some cases, for at least 5 years |
As a result, states make numerous efforts to provide essential health care for immigrant populations. Different states develop different solutions, all with the goal of extending coverage to the various groups that do not normally qualify for Medicaid and CHIP, but most frequently prioritizing children and pregnant women.
The House Republican bill includes a provision in section 44111 that would penalize states for providing health coverage to noncitizens by cutting the state’s Medicaid expansion FMAP from 90 to 80% – doubling the state share of Medicaid expansion costs. In the House Energy and Commerce Committee’s version of the bill, the FMAP penalty would have been imposed if the state provided coverage to “an alien who is not a qualified alien or otherwise lawfully residing in the United States,” essentially targeting the penalty only on expansion states who provide coverage with state-only funds to undocumented immigrants. This text remained unchanged through the House Budget Committee markup. However, when it came time for the House Rules Committee to prepare the bill for consideration by the full House, the text changed without explanation. The Rules Committee version eliminated the “or otherwise lawfully residing in the United States” clause, thereby imposing the expansion FMAP penalty on states that provide health coverage, “to an alien who is not a qualified alien.”
Close watchers of this process noticed the change immediately, and immigration and Medicaid experts understood its implications. Namely, in addition to penalizing expansion states that provide health coverage to undocumented immigrants with state-only funds (14 states, including DC), the provision would also penalize an additional 10 states states who have adopted the state plan option to waive the five-year waiting period for lawfully residing children and pregnant women (known as ICHIA or CHIPRA 214). It’s unclear whether lawmakers themselves understood the implications of the change, though signs point to “no” as the language underwent yet another unexplained change before the final House vote. In this iteration, which ultimately passed the House and is awaiting consideration in the Senate, the bill text would penalize states that provide health coverage to “an alien who is not a qualified alien and is not a child or pregnant woman who is lawfully residing in the United States and receiving medical assistance pursuant to section 1903(v)(4).” (See this and the related insertions beginning on page 9 of the manager’s amendment). Section 1903(v)(4) is the ICHIA option in Medicaid. Problem solved? Not exactly. (Perhaps this could be a lesson in why legislation should not be crafted in the middle of the night.)
Though purportedly aiming to “fix” the ICHIA problem they created, the new text fails to address lawfully residing children and pregnant women in separate CHIP programs. This and other problems for other populations are all described in greater detail below.
The bill (in any of the iterations so far) does not directly ban coverage of undocumented immigrants with state-only funds, nor does it remove the ICHIA option first added in the CHIP Reauthorization Act of 2009. Instead, the cuts are structured as a penalty on Medicaid expansion – states that provide coverage to the targeted immigrant groups would have their federal Medicaid expansion dollars reduced 10 percentage points – doubling the state cost. Perversely, the bill would severely punish Medicaid expansion states that, for example, cover lawfully present immigrant children in CHIP using ICHIA (such as IA, LA, PA, UT, and WV), while non-expansion states (such as FL and TX) that offer the exact same coverage for immigrant children would face no penalty at all. For the expansion states, it would be a cut so massive that it would force states to drop the immigrant coverage, while the non-expansion states could continue it.
Here are six populations that states currently choose to cover that would face cuts:
Figure 2
- Immigrant children in separate CHIP programs covered under ICHIA. The bill would effectively force states to end coverage for the two groups of children that qualify for CHIP in many of the states that have taken the ICHIA option. The two groups of children covered under the ICHIA option that would almost certainly lose coverage under the bill are:
- Qualified immigrant children in separate CHIP during the five year waiting period. Qualified immigrants are a subset of lawfully present immigrants (see Figure 2 above and legal definition under section 431(b) of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996), such as green card holders, asylees, and refugees who are eligible for Medicaid and CHIP, but in some cases subject to a five-year waiting period. (Some groups, such as refugees, are exempted from the five year waiting period.) Under the bipartisan ICHIA option, states may cover children (and pregnant women) that are qualified immigrants during the five year waiting period, so that there is no delay in their Medicaid or CHIP coverage. Under the House bill, states providing this coverage through separate CHIP programs would be subject to the penalty, forcing them to drop their coverage for qualified immigrant children in separate CHIP during the five year waiting period.
- Other lawfully present immigrant children in separate CHIP (at any time). In addition to using the bipartisan ICHIA option to provide coverage to qualified immigrants during the five year waiting period (as described in 1a. above), states also use ICHIA to provide coverage to other lawfully present children (and pregnant women) who are not in qualified status (see Figure 2). This includes, for example, individuals on student visas or under “temporary protected status” due to a war or natural disaster in their home country. Under the House bill, these children would also lose coverage when the state is forced to drop the ICHIA option.
- Immigrant pregnant women covered through separate CHIP. The bill would effectively force states to end coverage for two groups of pregnant women that qualify for separate CHIP in many of the states that have taken up the ICHIA option. The two groups of pregnant women covered under the ICHIA option that would almost certainly lose coverage under the bill are:
- Qualified pregnant women covered through separate CHIP during the five year waiting period. As described in #1, qualified immigrants are a subset of lawfully present immigrants who are eligible for Medicaid and CHIP, but in some cases subject to a five-year waiting period. Under bipartisan ICHIA, states have the option to cover pregnant women (and children) that are qualified immigrants during the five year waiting period, so that there is no delay in their Medicaid or CHIP coverage. Under the House bill, states providing coverage to pregnant women through an expansion of their separate CHIP programs would be subject to the penalty, forcing them to drop their coverage for qualified immigrant pregnant women in separate CHIP.
- Other lawfully present immigrant pregnant women in CHIP expansions (at any time). In addition to using the bipartisan ICHIA option to provide coverage to qualified immigrants during the five year waiting period (as described in 2a. above), states also use ICHIA to provide coverage to other lawfully present pregnant women (and children) who are not in qualified status. This includes, for example, individuals on student visas, business visas, or under “temporary protected status” due to a war or natural disaster in their home country. Under the House bill, these pregnant women would also lose coverage when the state is forced to drop the ICHIA option.
- Additional qualified individuals during the five year waiting period. The bipartisan ICHIA option to cover the five-year waiting period (described in #1a and #2a) only applies to qualified children and pregnant women. Some states use state-only dollars (as opposed to Medicaid funding which includes both state and federal dollars) to provide coverage to other qualified immigrants during the five year waiting period. Since it does not include federal Medicaid funding, this coverage is by definition not Medicaid. Under the House bill, these states would be forced to drop this state-only coverage or else face the penalty (loss of their federal Medicaid expansion dollars). Under this unprecedented and likely unconstitutional policy, the federal government would be withholding federal dollars based on coverage a state is choosing to separately and independently provide with its own state dollars.
- Other immigrants, including lawfully present and undocumented immigrants (at all times). Recognizing the importance of providing coverage to children, pregnant women, and others, some states use state-only dollars to provide coverage to immigrants who are not eligible for Medicaid and CHIP, which can include both lawfully present immigrants and undocumented immigrants. Since it does not include federal Medicaid funding, this coverage is by definition not Medicaid. As with #3 above, under the House bill, these states would be forced to drop this state-only coverage or else face the penalty (loss of their federal Medicaid expansion dollars). And as with #3 the federal government would be withholding federal dollars based on coverage a state is choosing to separately and independently provide with its own state dollars.
- Additional lawfully present and undocumented pregnant women with postpartum coverage (FCEP extension) funded through CHIP Health Services Initiatives. Some states extend FCEP (From Conception to End of Pregnancy) coverage for immigrants using a CHIP Health Services Initiative (HSI) to cover postpartum care regardless of immigration status. Under the House bill, states would be forced to terminate this coverage.
- Certain immigrants admitted due to urgent humanitarian reasons or significant public benefit. The Secretary of Homeland Security has authority to temporarily admit immigrants for urgent humanitarian reasons or significant public benefit (these immigrants are known as “parolees”). When such an admission is made for a year or more, the immigrant is treated as a qualified immigrant eligible for Medicaid. Under the House bill, any Medicaid coverage for this long-standing group of immigrants would trigger the penalty on Medicaid expansion funding. This is a clear attempt to force states to drop coverage of parolees admitted for a year or more, rewriting long-standing Medicaid eligibility rules to specifically exclude individuals admitted for urgent humanitarian reasons, among others.
These cuts will be incredibly harmful. Congress is going to extreme lengths when it targets lawfully present children covered through bipartisan legislation, similarly lawfully present pregnant women who will give birth to U.S. citizens, and individuals covered by state programs unrelated to Medicaid or the federal government.