Several policy changes taking effect this fall will negatively impact immigrants and mixed-status families. As my colleague Leo Cuello has pointed out, undocumented immigrants are not eligible to enroll in Medicaid coverage, therefore, this blog explains changes that apply to lawfully present immigrant families and children (many of whom are U.S. citizens). It’s also worth noting that immigrants use less health care and have lower health care costs than U.S.-born citizens.
This blog focuses on two significant developments:
- Changes to the public charge policy; and
- H.R. 1 provisions affecting Medicaid, CHIP, and Emergency Medicaid.
Public Charge
As we discussed in previous blogs, on July 20, 2026, the U.S. Department of Homeland Security (DHS) issued a final rule rescinding the 2022 public charge regulations. The rule took effect on September 18, 2026. It applies to applications to adjust immigration status and some applications for admission that are submitted on or after that date.
The public charge ground of inadmissibility is part of immigration law. Historically, it allowed immigration officials to determine whether a person was likely to become primarily dependent on the government for subsistence. A person found inadmissible on public charge grounds may be denied adjustment of status to lawful permanent residence or may in some circumstances be denied admission to the United States.
The new rule dramatically changes the “primarily dependent” standard and gives DHS officers broader discretion when considering the totality of an applicant’s circumstances when making a public charge determination. The rule also expands the range of public benefits that officers may consider.
Although public charge determinations apply to the applicant, these recent changes may create significant fear and confusion in mixed-status families. As previously mentioned, DHS officers have broad discretion and could in some cases include benefits used by U.S. citizen family members, including citizen children, in their determinations.
The rule has already prompted legal challenges. On September 14, 2026, a coalition of 22 states and the District of Columbia filed suit, arguing that the rule violates the Immigration and Nationality Act and the Administrative Procedure Act. A separate coalition of cities and counties has filed a similar challenge.
It is important for advocates and immigrant families alike to remember that many legal immigration statuses have no established pathway to residency (thus public charge may not be practically relevant to some individuals) and that there are many immigration statuses that are protected by law from public charge policy, including refugees, asylees, crime and abuse related statuses, and numerous other humanitarian statuses. Without access to accurate information, many immigrants may avoid publicly funded health programs even though the public charge policy doesn’t impact them.
H.R. 1 Provisions Affecting Medicaid and CHIP
Among its many provisions, H.R. 1 limits the circumstances under which states may receive federal Medicaid and CHIP funding for people in certain immigration categories.
Beginning October 1, 2026, federal matching funds for full Medicaid and CHIP coverage will generally be available only for a narrower group of people, including:
- U.S. citizens;
- Lawful permanent residents (aka green card holders), though they may remain subject to the five-year waiting period depending on their state’s policy decision;
- Citizens of Compact of Free Association nations residing in the United States; and
- Certain Cuban and Haitian entrants.
These changes do not eliminate the state options to provide coverage to lawfully residing children and/or pregnant women under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Section 214 option, also known as the ICHIA option. They also do not eliminate coverage available through the from-conception-to-end-of-pregnancy (FCEP) option. Individuals losing general eligibility on October 1 can be eligible for either of these options if the state chooses to offer the coverage option, as discussed further below.
Changes to Emergency Medicaid Matching Funds
H.R. 1 also changes the federal matching rate for Emergency Medicaid.
Historically, Emergency Medicaid services have generally received the applicable federal matching rate associated with the individual’s Medicaid eligibility group. For example, Emergency Medicaid services provided to individuals who would qualify for the Medicaid expansion group but for their immigration status have been reimbursed at the special 90 percent federal matching rate that generally applies for Medicaid expansion enrollees.
Beginning October 1, 2026, H.R. 1 limits the federal matching rate for Emergency Medicaid services to the state’s regular Medicaid matching rate. For Medicaid expansion states, this means that the federal matching rate will fall from 90 percent to the state’s regular rate, generally between 50 and 77 percent depending on the state.
This change affects federal financing; it does not change Emergency Medicaid eligibility or the scope of emergency services that must be covered under federal law. However, states may face increased financial pressure as they receive less federal funding when more immigrants lose eligibility for full-scope Medicaid and rely on Emergency Medicaid for care.
Advocates should monitor whether states respond to the reduced federal funding by:
- Adopting stricter definitions of emergency medical conditions;
- Reducing provider reimbursement rates;
- Changing administrative procedures; or
- Creating other barriers to Emergency Medicaid enrollment or payment.
State Policies That Can Mitigate Harm
Although H.R. 1 restricts federal Medicaid and CHIP funding for many immigrants, it does not eliminate certain state coverage options discussed above. States can use these options to reduce coverage losses.
ICHIA Coverage
The CHIPRA section 214 option or ICHIA allows states to provide Medicaid and CHIP coverage to lawfully residing children and/or pregnant women, including those who would otherwise be subject to the five-year waiting period.
As my colleague Kelly Whitener has pointed out, H.R. 1 did not eliminate or alter this state option. As a result, individuals who currently qualify under ICHIA will continue to remain eligible in states that have adopted the option.
Furthermore, in states that offer ICHIA, children and/or pregnant women who lose coverage through the general Medicaid eligibility pathway for qualified immigrants should be able to transition to coverage through the ICHIA pathway, if their state offers ICHIA coverage. For example, a refugee child who loses general eligibility for Medicaid on October 1 should still be able to qualify for Medicaid through ICHIA.
States that have not adopted ICHIA should consider doing so as one way to reduce coverage losses for children and/or pregnant women resulting from H.R. 1, including incredibly vulnerable groups such as refugee children, victims of domestic violence and sex trafficking, among others.
Emergency Medicaid
Although H.R. 1 reduces the federal matching rate for Emergency Medicaid, Emergency Medicaid remains available to income-eligible individuals regardless of immigration status when they need treatment for an emergency medical condition.
Approximately half of Emergency Medicaid spending is associated with labor and delivery services. The program also covers treatment and stabilization for other emergency conditions. This coverage should be provided to immigrants who lose general Medicaid eligibility but are experiencing a medical emergency. For example, a refugee who loses eligibility for full-scope Medicaid but is hospitalized with pneumonia and complications may qualify for Emergency Medicaid for the treatment and stabilization of the emergency condition, including complications such as sepsis.
It is important to note that Emergency Medicaid applicants generally must establish that they have an emergency medical condition. This determination is an additional step in the Medicaid eligibility process and generally requires some kind of documentation, such as a medical confirmation from a provider.
What Policymakers and Advocates Can Do to Mitigate Harm
As October 1 approaches, policymakers and advocates should monitor:
- State notices providing information about, changing, or terminating Medicaid or CHIP coverage, which may be sent to immigrants who are not actually impacted or may be missing critical information for immigrants to understand or take action in response to the notices;
- The effectiveness of state eligibility systems to transition immigrants into ICHIA, FCEP, or Emergency Medicaid coverage, as applicable, if they lose full or general Medicaid eligibility;
- Changes to Emergency Medicaid application procedures, reimbursement rates, or access generally;
- Implementation of the new public charge policy and the chilling effect on immigrant families, including legal permanent residents and citizens in mixed status families.
States can reduce the harm caused by H.R. 1 by proactively providing clear and language-accessible notices and public messaging for immigrants, establishing or maximizing multi-lingual consumer assistance services, adopting and effectively implementing available coverage options (such as ICHIA, FCEP, and Emergency Medicaid), developing policies to protect the safety and confidentiality in accessing health care and related programs, and encouraging or requiring providers to adopt similar policies.