1. Overcoming Barriers to Access to Health Care by Immigrant Families Sonal Ambegaokar, Health Project Manager National Immigration Law Center March 4, 2013

2. What Barriers or Concerns do Immigrant Families Have?

3. Helping with the Application – Whose Info is Needed? Goal: To make the application process put immigrant and mixed-status families at ease and be sensitive to their concerns. From the start, application should make clear that an individual can apply on behalf of someone else in the family. Request sensitive info only of applicant Make clear that non-applicants will not have to provide their SSN or citizenship/immigration status in order to complete the application.

4. Helping with the Application – Social Security Numbers and Individual Taxpayer Identification Numbers (ITINs) SSNs will be primary gateway to the electronic verification system (the federal hub), including IRS data. Applicants must provide SSN, IF they have one Eligibility determination and enrollment should proceed pending issuance of SSN or if only eligible for non-work SSN Request for SSN of non-applicants must: Make clear it is optional/voluntary Not be required to proceed in electronic application Explain how the SSN will be used and shared to determine eligibility for those seeking coverage

5. Helping with the Application – Immigration Status Requirements Exchange and Medicaid/CHIP have different immigrant eligibility rules; eligibility varies from state to state Date of Entry: N/A for Exchange – no 5-year bar for eligible immigrants in Exchange; N/A for certain immigrants for Medicaid/CHIP Screen first for income, then get into details about immigration status Have cheat sheets and info on eligible immigration statuses handy Provide multiple notices and reassuring messages about privacy, confidentiality, and public charge

6. Helping with the Application – Verifying Citizenship or Immigration Status Citizenship- electronic database match via SSN - SSA, Vital Statistics, other databases, SAVE Ensure opportunity to provide alternative proof of citizenship if unable to match via electronic match or do not have SSN Naturalized citizens have higher error rates in SSA database match Immigration status - Federal data services hub will use SAVE Provide clear notice that immigration status will be verified only to determine eligibility and not for immigration enforcement or other purposes Ensure applicants who are otherwise eligible and provide proof of status to be aided pending verification without delay

7. Helping with the Application – Documentation of Income Variety of workers whose income not recorded by IRS or state wage databases will need to provide additional info. Electronic data matching preferred – could be done using data fields other than SSN What happens when the hub can’t verify income? Self-attestation of income should be allowed when documentation does not exist or is not reasonably available

8. Privacy, Security & Confidentiality Need to address concerns about what info is collected, how it is shared, and unintended consequences. Info can be collected, used or disclosed ONLY if necessary to carry out Exchange functions (eligibility determination and enrollment in health insurance) Info can only be used by/disclosed to those authorized to receive or view it Exchange will require the same or more stringent privacy and security standards as a condition of contract or agreement with individuals or entities (Navigators, agents, and brokers). Exchange must ensure workforce compliance; training No immigration consequences Department of Homeland Security does NOT engage in enforcement activities based on a SAVE inquiry No “public charge”

9. Language Barriers Medi-Cal and Covered California or other entities that receive federal funding) MUST provide free oral interpretation services and translate key documents into top languages.

10. Strategies to Enroll Immigrant Families Provide a safe environment in which immigrants, LEP persons, and other vulnerable populations can seek services and information Include reassuring language on application, instructions, notices, outreach & education materials

11. Strategies to Enroll Immigrant Families Provide free interpretation and translation services All settings – call center, website, in- person, Navigators, consumer assistance programs Include tag lines on written materials and website Budget for appropriate language assistance services

12. Strategies to Enroll Immigrant Families Eligibility workers, call center personnel, Navigators, consumer assistance programs Include training on immigrant eligibility, immigrants’ concerns, language access policies, privacy & confidentiality procedures Recruit culturally & linguistically appropriate workforce, including organizations trusted by immigrant communities