By Dinah Wiley

In previous blogs, I’ve described the reluctance of immigrant families to enroll in Medicaid, CHIP, or marketplace insurance and subsidies.  The chief worry for a mixed-status household is whether a health insurance application will trigger immigration enforcement, resulting in “removal” (deportation) of a member of the family who would be separated from their loved ones. Since Affordable Care Act enrollment began this month, immigrants, providers and advocates have emphasized that this fear is a major barrier keeping immigrant families from applying for health coverage.  Although ACA regulations block the use of immigration status information for purposes other than an eligibility determination, technical rules cannot convey a convincing message that it is really safe to apply.

The Administration has now addressed this need and concern head-on.  HHS and the Department of Homeland Security (DHS) immigration enforcement arm, have simultaneously released welcome guidance announcing that it is safe for mixed-status families to apply for their eligible family members without fear of immigration enforcement consequences.  This means that an ineligible Mom or Dad should feel comfortable enrolling their eligible children, spouse, and other dependents even though they themselves aren’t applying.

On the DHS side, U.S. Immigration and Customs Enforcement (ICE) announced in a memo that information obtained through the health care application process will not be used for civil immigration enforcement activity such as removal/deportation. The ICE policy (released in English and Spanish) protects information about the immigration status of applicants, beneficiaries, enrollees, and their household members.  ICE’s firewall protects against disclosure of information about immigration status regardless of whether ICE receives it through normal ACA verification procedures or from another source (such as a Medicaid or marketplace employee or assister who reports someone).

While ICE protects the information at the back end, the CMS guidance  reinforces this protection at the front end, where applicant families give information about their immigration status or Social Security numbers (SSNs) to health care agencies, which then transmit the information to DHS or the Social Security Administration for verification.   The new CMS guidance, in FAQ format, announces that “Information provided by applicants or beneficiaries won’t be used for immigration enforcement purposes.”  All who work with immigrant communities can help connect them to care by getting out the word on these government policies.  The FAQ is written in  plain language suitable for distribution to consumers and will be translated into Spanish.

CMS Addresses “Public Charge” and Other Enrollment Barriers

CMS’ FAQ includes other messages critical to immigrant families.  First, it bolsters the “safe to apply” message by emphasizing the regulatory restrictions on inquiries into the immigration status and Social Security numbers of family members who are not applying for health coverage for themselves.  For more details about how the ACA regulations handle verification of immigration status and SSNs, see my previous blog.

Second, the FAQ provides vital information about “public charge,” a persistent barrier to enrollment which HHS materials on health reform have not previously addressed.  This is a concern that applying for health insurance and help with its costs will result in denial of a green card on public charge grounds.  [Before granting lawful permanent residence (LPR or green card status), immigration authorities must determine that the applicant is not likely to become a public charge, or primarily dependent on the government for subsistence.]  The CMS FAQ confirms that receiving help with costs of health insurance will not make one a public charge.  The sole exception is for the non-citizen who receives long-term institutionalization at government expense.

For those familiar with public charge policy, this announcement may not seem new.  Since 1999, the Administration has said that applying for Medicaid and CHIP will not be a factor in public charge determinations.  Still, public charge has remained a persistent barrier to enrollment in coverage through the health care safety net; immigration attorneys frequently advise their clients not to enroll.  Advocates and state agencies can facilitate non-citizen participation in the benefits of health reform by informing immigrant communities of this latest Administration announcement:  applying for health coverage or help with costs through Medicaid, CHIP, or the marketplaces will not affect someone’s chances of becoming a lawful permanent resident or a citizen.

Eligibility Questions Also Answered

The guidance answers another frequently-asked question about whether very low-income immigrants who can’t get Medicaid can apply to the marketplace for help with costs.  The FAQ confirms that immigrants whose household income is below poverty, and who are not eligible for Medicaid, are eligible to apply for marketplace premium tax credits and cost-sharing reductions.  Non-citizens who are otherwise eligible for help with costs may apply to the marketplace even at the very low-income levels of 0-100% FPL which would otherwise make them eligible for Medicaid.  This special ACA rule ensures that low-income, lawfully present immigrants who can’t get Medicaid because they don’t meet Medicaid’s strict immigrant eligibility rules do not lack an option for coverage under health reform.

Finally, the CMS FAQ also addresses widespread confusion over the immigration status categories that make a non-citizen eligible for coverage.  The guidance compiles in one place, information about the immigration status categories that confer eligibility for Medicaid, CHIP, the marketplace and the ACA subsidies.  The non-citizen eligibility rules are highly complex.  Accurate, reliable government information like that found in the FAQ is an antidote to lack of participation resulting from the confusion of consumers, assisters, and government agencies about which immigrants, and/or which members of immigrant families, are eligible to purchase through the marketplace and to enroll in one of the insurance affordability programs.  In addition, the FAQ reminds undocumented immigrants that they may be eligible for emergency Medicaid and other health care programs in their state.  For more background on eligibility based on immigration status, see the first blog in this series.  And look for another resource soon when the National Immigration Law Center posts their FAQ on health care for mixed status families, at www.nilc.org.

(For those readers involved in outreach and enrollment efforts, please feel free to use our free Spanish language Public Service Announcement.)