Immigrant eligibility for care and coverage in the ACA era Joel Diringer, JD, MPH January 2016

Today’s topic: Eligibility of immigrants for health coverage programs 1. Definitions 2. Specific populations Legal immigrants – ACA and California DACA in California Undocumented immigrants Employer coverage Mixed status families 4. Public charge issues 5. Overcoming barriers 6. Questions

Definitions “Lawfully present” immigrants Undocumented immigrants On road to citizenship – e.g. Legal Permanent Resident (LPR) Permission to stay indefinitely in US without pathway to citizenship Temporary Protected Status including PRUCOL and DACA “Dreamers”. (Note: DACA not eligible for ACA purposes) Permission to stay temporarily (e.g. visa holders) Undocumented immigrants Persons who lost permission to remain in US or entered without inspection

“Lawfully present” immigrants under the Affordable Care Act Can buy health insurance in Covered CA with own funds May qualify for premium and co-pay subsidies in Exchange (up to 400% if <5 years; 100-400% if >5 years) May qualify for full-scope Medicaid (Medi-Cal) Are subject to the individual mandate

Lawfully present immigrants -- Medi-Cal – California rules All legal immigrants are eligible “Permanently Residing Under Color of Law (PRUCOLs)” – are eligible 15 categories plus catch-all: Immigration authorities are aware of presence and has no intention of deporting Self certification of PRUCOL status (MC-13)

Deferred Action for Childhood Arrivals (DACA) DACA eligibles are not eligible for Covered California Health Plans, but they are eligible for Medi-Cal in California. However, a DACA-eligible individual may still apply through Covered California as they may be eligible to receive low or no-cost health coverage through Medi- Cal. DACA/DAPA expansion on hold by federal court.

Undocumented Immigrants Cannot buy insurance in individual market of Covered California, even at full cost Cannot receive subsidies through Covered CA Excluded from individual mandate for selves, but not for eligible family members Can be covered by employer (including in SHOP), or purchase individual policy outside Exchange Eligible for some Medi-Cal services; also Breast Cancer and Cervical Cancer Treatment, Family PACT, CHDP, WIC, Medi-Cal Access Program (AIM) Can obtain services from FQHCs, emergency rooms and other clinics and some county programs

Undocumented immigrants Medi-Cal coverage Restricted/Emergency Medi-Cal for emergency services and pregnancy Full-scope coverage for all children regardless of immigration status no sooner than May 2016 Hospital Presumptive Eligibility Apply through hospital for full-scope Medi-Cal benefits – up to 2 months eligibility – once a year for adults, twice a year for children. No immigration screen. CHDP Gateway Apply through CHDP provider for up to 2 months eligibility; now twice a year for children. No immigration screen.

Undocumented immigrants Employer-based coverage Employers with 50 or more full-time equivalent workers are required to offer affordable, comprehensive coverage to full-time workers and dependent children, or pay penalties to the federal government. Employee cost cannot exceed 9.66% of their income. Coverage must pay for at least 60% of average health costs (minimum value). No responsibility to pay for children’s coverage. Seasonal workers expected to work fewer than 6 months are excluded from the mandate.

Mixed-status immigrant families US Citizen or LPR children/spouses – have same rights as other citizens Undocumented adults can apply for Exchange subsidies for eligible family members, but must be tax-filer (with ITIN) Individuals who are not “lawfully present” will not be counted in the household/family size and the household income will be proportionally adjusted (reduced) based on a formula created by the ACA While undocumented persons are exempt from the individual mandate, they are subject to the tax penalty for not covering those subject to individual mandate

Immigration Public Charge In general, applying for insurance through Covered California, receiving tax credits for a Covered California Health Plan or receiving low or no-cost coverage through Medi-Cal, will not make an individual a “public charge” – it will not affect a person’s immigration status, chances of becoming a lawful permanent resident, or becoming a naturalized citizen. The exception is if the individual receives long term care in a nursing home or other facility paid for by the government, or does not tell the truth on the application.

Overcoming barriers Clear, concise and accurate information that is linguistically and culturally appropriate Be creative – DACA eligibility? Hospital presumptive eligibility? PRUCOL? Information provided by persons trusted in the community Hands-on assistance by experienced counselors in applicant’s language Be sensitive to fears and reticence of accepting government assistance Continued assistance in paying premiums, finding providers, making appointments, understanding health plan (e.g. co-pays, deductibles, in-network providers) and renewal.

Additional resources QUESTIONS? http://undocumentedanduninsured.org/ http://www.caimmigrant.org/what-we-do/healthcare/ QUESTIONS?

Diringer and Associates Joel Diringer, JD, MPH Diringer and Associates 2475 Johnson Avenue San Luis Obispo, CA 93401 805-546-0950 joel@diringerassociates.com www.diringerassociates.com