ONUS Region 9 Meeting September 19, 2017 Is immigration status always a barrier to obtaining Medicaid coverage for an organ transplant?  ONUS Region 9 Meeting September 19, 2017

LegalHealth’s Mission Since 2001 LegalHealth has partnered with medical professionals to address the nonmedical needs of low-income people with serious health problems. LegalHealth is part of the New York Legal Assistance Group, a nonprofit law office. LegalHealth is funded through private foundations and its partners. LegalHealth is the largest medical-legal partnership in the country. LegalHealth partners with 30 health care facilities in NYC and Long Island.

Immigration Status as a Barrier to Organ Transplant Ibrahima, a 47 year old man, came to the US in 1996 from Guinea, which had a military government. He overstayed his tourist visa, making his undocumented, and has lived here and raised a son supporting his family driving a livery car. Over seven years ago, Ibrahima was diagnosed with End Stage Renal disease and began 3x week dialysis. His physicians thought he was a good candidate for a kidney transplant, however, he only had Emergency Medicaid and could not be listed. Sound familiar?

Is Immigration Status Always a Barrier to an Organ Transplant? Here’s Ibrahima today … One year post kidney transplant What changed for him?

Learning Objectives Provide basic understanding of insurability of immigrants. Nationally New York & Vermont State level Raise awareness of role of immigration attorney when considering insurability of an immigrant patient Familiarize you with special circumstances that may lead to changed immigration status Answer questions

Emergency Medicaid Emergency Medicaid provides payment for treatment of an emergency medical condition for people who meet all Medicaid eligibility criteria in the state (such as income and state residency), but don’t have an eligible immigration status. Emergency Medicaid does not cover organ transplants

National Landscape Most people in the following groups are eligible for coverage through the Health Insurance Marketplace (ACA): U.S. citizens U.S. nationals Lawfully present immigrants Generally, undocumented immigrants aren’t eligible to buy Marketplace health coverage, or for premium tax credits and other savings on Marketplace plans. https://www.healthcare.gov/immigrants/coverage/

National Landscape: “Lawful present” includes “Qualified non-citizen” 5-year waiting period for many qualified non-citizens to receive Federal Medicaid or CHIP Exceptions include, refugees, asylees, or LPRs who used to be refugees or asylees Humanitarian statuses or circumstances (including Temporary Protected Status, Special Juvenile Status, asylum applicants, Convention Against Torture, victims of trafficking) Valid non-immigrant visas Legal status conferred by other laws (temporary resident status, LIFE Act, Family Unity individuals) full list of immigration statuses eligible for Marketplace coverage.

Vermont expanded Medicaid eligibility under Affordable Care Act Lawfully residing children and pregnant women are now eligible for Medicaid during 5-year waiting period. Funded by State Medicaid dollars

New York has long had more expansive Medicaid eligibility Qualified residents during 5-year waiting period TPS, DACA (until expiration) PRUCOL aliens Funded through ACA Medicaid Expansion dollars for the Essential Plan and NYS Medicaid dollars

New York: PRUCOL NYS Constitution and Alliessa case establishes NYS Medicaid eligibility for individuals permanently residing under color or law (PRUCOL) PRUCOL is not an immigration status PRUCOL is New York State’s benefit eligibility category for Medicaid PRUCOL alien’ refers to an alien who is permanently residing in the United States with the “knowledge and permission or acquiescence” of the federal immigration agency and whose departure from the U.S. the agency does not contemplate enforcing.’ 18 NYCRR §360-3.2(j)(1)(ii); State of New York Department of Health Information Letter (08-OHIP/INF-4).

PRUCOL There is no PRUCOL application filed with immigration. Rather, immigration filings may make a client PRUCOL under the NY rules, such as: Pending application for a green card Approved Relative Petition (I-130) but no green application has been filed Aliens who have applied for or been granted medical deferred action Aliens who have applied for other immigration statuses including: TPS (Temporary Protected Status) & DACA (being cancelled); U/T Visa as a victim of a qualifying crime/trafficking; VAWA for abused spouses of USCs or LPRs Stay of Removal/Deportation or under an Order of Supervision Other applications for a permanent/long term benefit

Who Is Not PRUCOL? Visitors with valid visitors’ visas Generally, persons with denied applications for immigration relief Persons with final orders of deportation, unless deportation is being deferred/under Order of Supervision Persons who never filed for any immigration benefit or are ineligible for any immigration benefit

Role of Immigration Attorney for Patient Comprehensive screening and immigration intervention is to move people up the “flag pole” to more regularized status and greater protections, benefit eligibility and travel options. Citizen Lawful Permanent Resident Semi-status Lawful Non-immigrants Unlawfully present

Important Factors in Legal Analysis and Recommendations Every client presents with his/her own set of facts and each case must be examined carefully considering that client’s: Immigration History Criminal History Medical Needs Cases often require months of evaluation/waiting for immigration records

What changed for Ibrahima? Ibrahima’s physician referred him to the onsite legal clinic at the hospital. The attorney met with him to do a full immigration screening, analyzed his immigration history, and determined that upon his son’s 21st birthday, the son could file a family relative petition for Ibrahima. After the petition was filed and acknowledgment of receipt was received, Ibrahima was eligible to apply for NY Medicaid. Not only has he been transplanted, but he is also in the process of adjusting his status to become a lawful permanent resident (a/k/a green card).

Public Charge Applying for Medicaid or CHIP, or getting savings for health insurance costs in the Marketplace, doesn’t make someone a "public charge." This means it won’t affect their chances of becoming a Lawful Permanent Resident or U.S. citizen. There’s one exception. People receiving long-term care in an institution at government expense may face barriers getting a green card.

Concluding Remarks No one size fits all approach for clients when we are in the immigration arena. LegalHealth clinics and locations can be found at http://legalhealth.org/schedule/ Contact information: Julie Brandfield, Esq., Associate Director, LegalHealth jbrandfield@nylag.org