Overview of Immigrant Eligibility Policies and Enrollment Processes for Health Insurance Affordability Programs Presented in Partnership by the National.

Overview of Immigrant Eligibility Policies and Enrollment Processes for Health Insurance Affordability Programs Presented in Partnership by the National Immigration Law Center and Center on Budget and Policy Priorities July 29, 2015

Medicaid, KidCare and Marketplace Eligibility for Immigrants
Part I: Medicaid, KidCare and Marketplace Eligibility for Immigrants

General Immigrant Eligibility Rules for Medicaid and KidCare (including CHIP)
Under the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, the following groups may be eligible for Medicaid and CHIP: “Qualified" immigrants who entered the U.S. before 8/22/96 "Qualified" immigrants who reach the end of a 5-year waiting period For example: lawful permanent residents/green card holders "Qualified" immigrants exempt from the 5-year waiting period refugees asylees Cuban/Haitian entrants trafficking survivors veteran families NOTE: Immigrants who do not meet these immigrant eligibility rules (i.e. “qualified” immigrants in the 5-year bar and “not qualified” immigrants) may be eligible for Medicaid payment of limited emergency services (Emergency Medical Assistance – EMA) if they otherwise meet all Medicaid eligibility standards

“Qualified” Immigrants for Medicaid and KidCare
Categories defined by statute; Many of these are exempt from the 5-year bar Lawful Permanent Residents (LPR/green card holders) Refugees Asylees Cuban/Haitian entrants Persons who were paroled into the U.S. for more than a year Conditional entrants Certain domestic violence and trafficking survivors and their derivatives Certain American Indians Persons granted withholding of deportation/removal

Five-Year Waiting Period for Medicaid & CHIP
Many “qualified” immigrants who entered the U.S. on or after August 22, 1996 are subject to a 5-year waiting period (also know as “the 5-year bar”) The five years begin when an immigrant obtains a “qualified” immigration status Many “qualified” immigrants are not subject to the 5-year bar: Refugees, asylees, persons granted withholding of deportation/removal (even if they later become LPRs) Cuban/Haitian entrant, Amerasian, Iraqi or Afghan special immigrant status, trafficking survivor (even if they later become LPRs) Qualified immigrants who are U.S. veterans or on active military duty and their spouses or children

Cuban/Haitian Entrants
Defined broadly for benefits purposes, including Medicaid, KidCare and ACA Includes many different types of statuses; most Cuban or Haitians will fall under this category (except Haitians with Temporary Protected Status, TPS). Includes nationals of Cuba or Haiti who: were paroled into the U.S., regardless of whether the parole document states “Cuban/Haitian entrant”; or have a pending exclusion or deportation case, or applied for asylum, provided that they are not subject to a final order of deportation or exclusion; or others A national of Cuba or Haiti in another qualified category (e.g. LPR) may have been a Cuban/Haitian entrant at some point in the past: This may impact eligibility but may not show up when Medicaid or the Marketplace tries to initially electronically verify immigration status This group may need more assistance than others May depend on past status – won’t show up on first SAVE check. Sometimes their records to prove status are really old, need manual check. This is a group that might need more assistance than others. Don’t give up. Paroled into the US - permitted to enter the country for humanitarian or public interest reasons Can be temporarily, or With understanding that they will remain permanently by applying for asylum or filing a family visa petition

MediKids and Healthy Kids
MediKids: children 1-4 years old Healthy Kids: children 5-18 years old Coverage is similar to Medicaid and includes doctor visits, immunizations, dental care, emergency care, hospital stays and more Low-cost coverage for children ineligible for Medicaid due to income (on sliding scale) or immigration status (at full cost) Apply using KidCare application If get a question about it: KidsWell campaign – ICHIA for kids From Miriam - Regarding KidCare., as you probably know, there are no rules because it is not administered by a state agency. The spokesperson I called said that there is still a full pay option for ineligible kids, but he cautioned that rates will be going up significantly as the plan complies with the ACA. Right now the premium is $153/month and it going up to $200 you may or may not want to mention this. In terms of undocumented kids, they have been eligible for full pay but the KidCare program is planning to adopt a waiting period to eliminate coverage for “medical tourists”. They are currently thinking of 3 years. I told him I thought the policy purpose could be served with a much shorter time frame. He said we could submit comments, but, again, as they are not a state agency, no APA rule development and comment provisions apply.

Emergency Medical Assistance (EMA)
Medicaid payment for limited services related to an emergency medical condition Is available to people who meet all the state’s Medicaid eligibility requirements except for citizenship or immigration status, including: Qualified immigrants who have not met the five-year bar requirement Lawfully present, but not qualified immigrants, such as nonimmigrant visa holders (e.g., students, temporary workers, etc.), Temporary Protected Status (TPS) and many others, Undocumented immigrants Will cover dialysis for persons with End Stage Renal Disease (ESRD) Once determined to meet Medicaid requirements (income, residence, etc.) except for citizenship or immigration status, eligible for 12 months for applicable emergencies (i.e. don’t have to reapply each month or with each emergency) Re EMA: I think important point to make is that individuals have 12 months of eligibility in terms of providing all elements of eligibility (income , residence, etc.) save for the medical emergency. People no longer have to reapply every month. This was new policy negotiated for dialysis patients in 2010 who had been getting EMA. Sometime prior to 2010 state officials had decided –under the radar with no legislative approval that i’m aware of—to treat dialysis as emergency so dialysis was the one ongoing outpatient service that was treated as an “emergency.”. But providers were having difficulty billing because the patient had to keep reapplying each month. So this was super helpful for dialysis patients and providers,

“Lawfully Present” Immigration Categories Eligible for Marketplace Coverage: Part I
“Qualified” Immigrants: Other Lawfully Present Immigrants: Lawful Permanent Resident (LPR/green card holder) Refugee Asylee Cuban/Haitian Entrant Paroled into the U.S. Conditional Entrant Battered Spouse, Child and Parent Trafficking Survivor and his/her Spouse, Child, Sibling or Parent Granted Withholding of Deportation or Withholding of Removal Others: Certain American Indians Granted relief under the Convention Against Torture (CAT) Temporary Protected Status (TPS) Deferred Enforced Departure (DED) Deferred Action* Individual with Nonimmigrant Status (includes worker visas; student visas; U visas; citizens of Micronesia, the Marshall Islands, and Palau; and many others) Administrative order staying removal issued by the Department of Homeland Security Lawful Temporary Resident *EXCEPTION: Individuals granted deferred action under the Deferred Action for Childhood Arrivals (DACA) program are not eligible to enroll in coverage in the Marketplace. Source:

“Lawfully Present” Immigration Categories Eligible for Marketplace Coverage: Part II
Applicant for any of these statuses: With Employment Authorization: Lawful permanent resident (LPR/Green Card) Special Immigrant Juvenile Status Victim of Trafficking Visa Asylum* Withholding of Deportation or Withholding of Removal, under the immigration laws or under the Convention Against Torture (CAT)* Applicant for Temporary Protected Status Registry Applicants Order of Supervision Applicant for Cancellation of Removal or Suspension of Deportation Applicant for Legalization under IRCA Legalization under the LIFE Act *Only those who have been granted employment authorization or are under the age of 14 and have had an application pending for at least 180 days are eligible Source:

Lawfully Present Immigrant Seniors
Medicare has different rules – qualifying work history and immigration status restrictions Some lawfully present seniors, including LPRs, may not be eligible for Premium Free Medicare because they lack qualifying work history Some LPRs may be eligible only for Premium “Buy-in” Medicare Lawfully present seniors who are not eligible for Premium Free Medicare are eligible for premium tax credits to offset the cost of Marketplace plans

General PTC Eligibility for Lawfully Present Adults
MAGI Medicaid Coverage Landscape for Adults Adults with Dependent Children Adults without Dependent Children

Undocumented & DACAmented Individuals
Ineligible to purchase qualified health plans in the individual Marketplaces, even at full price Can purchase private coverage outside the Marketplace or through employer Exempt from the individual mandate as “exempt non-citizens,” along with individuals who are “non-resident aliens” under tax law Can apply for health insurance for eligible family members, or be part of household of eligible family members If applying for premium tax credits on behalf of eligible family members, must file a tax return. If not eligible for a Social Security number (SSN), may file a tax return using an Individual Taxpayer Identification Number (ITIN) Can use health programs available to ALL, regardless of immigration status

Health Programs Available to ALL
MediKids and Healthy Kids - at full price Hospital financial assistance programs or charity care Community Health Centers/FQHCs, Migrant Health Centers Programs using federal health care block grants: Mental health, maternal and child health, family planning, communicable diseases, immunizations Programs providing health services necessary to protect life or safety: Emergency medical, food, or shelter, mental health crisis, domestic violence, crime victim assistance, disaster relief

Immigrant Eligibility Scenarios
Part II: Immigrant Eligibility Scenarios

Scenario 1: Ricky, Eva and Karina
Ricky and Eva are not married but live together with their daughter, Karina Karina was born in Florida and is a U.S. citizen Ricky is undocumented and not applying for coverage Eva received Deferred Action for Childhood Arrivals (DACA) in 2012 and she: Earns $37,601 a year Plans to file federal taxes and will claim Ricky and Karina as dependents Ricky and Eva are applying for coverage for Karina

Eligibility for Health Coverage Programs
Eligibility Based on General Citizenship / Immigration Status Rules Ricky Applying for coverage: Citizen: Immigration Status: Qualified Immigrant: No n/a Subject to 5-year bar: Satisfied 5-year bar: Lawfully Present: Eva Karina Yes MAY BE ELIGIBLE FOR: Medicaid/KidCare QHP Enrollment

Eligibility for PTC and Medicaid
Medicaid/KidCare Premium Tax Credits Eligible? HH Income FPL* Ricky N/A -- Eva Karina Yes 3 $37,601 187% No 190% Ricky is not applying for coverage: he would not meet the immigration requirement for insurance affordability programs Eva is not applying for coverage: she would not meet the immigration requirement to enroll in insurance affordability programs because of the exclusion of DACAmented individuals, even though she is authorized to work in the U.S. and has a SSN Karina is eligible for KidCare Note: Ricky and Eva are not subject to the penalty for going without coverage *Medicaid currently uses the 2015 federal poverty line for determining eligibility and the Marketplace currently uses the 2014 federal poverty line for determining eligibility for premium tax credits

Scenario 2: Mei, Michael and Lin
Mei lives with her son, Michael, and father Lin She has been a lawful permanent resident (LPR) for 6 years Michael is a citizen and is enrolled in his father’s employer sponsored health insurance Lin has been a LPR for 2 years He has not worked the 40 quarters and is not enrolled in Medicare He is Mei’s tax dependent Mei earns $17,811 a year Mei and Lin are applying for coverage

Eligibility Based on General Citizenship / Immigration Status Rules Mei Applying for coverage: Citizen: Immigration Status: Qualified Immigrant: Yes No LPR Subject to 5-year bar: Satisfied 5-year bar: Lawfully Present: MAY BE ELIGIBLE FOR: Medicaid QHP Enrollment Lin Michael n/a

Eligibility for PTC and Medicaid
Medicaid/KidCare Premium Tax Credits Eligible? HH Income FPL* Mei No 3 $17,811 89% 90% Lin 1 $0 - Yes Michael N/A -- Mei is not eligible for Medicaid because her income is above the 30% FPL limit for parents and Florida has not expanded Medicaid Mei is not eligible for PTC because her income is below 100% FPL Lin is a qualified immigrant but has not met the five- year bar for Medicaid eligibility Lin is eligible for PTC even though his income is below 100% FPL because he does not meet the Medicaid immigration requirement Note: Lin has opted not to enroll in Medicare because he would have to pay the full premium *Medicaid currently uses the 2015 federal poverty line for determining eligibility and the Marketplace currently uses the 2014 federal poverty line for determining eligibility for premium tax credits

Scenario 3: Daniel, Marie and Amina
Daniel and Marie are married and have a daughter, Amina Daniel and Marie: Entered the U.S. as Cuban/Haitian entrants 4 years ago Became LPRs 1 year ago Amina is a citizen and enrolled in KidCare Daniel earns $18,800 a year Daniel and Marie file taxes jointly and claim Amina as a dependent

Eligibility Based on General Citizenship / Immigration Status Rules Marie Applying for coverage: Citizen: Immigration Status: Qualified Immigrant: Subject to 5-year bar: Satisfied 5-year bar: Lawfully Present: Yes No Cuban/Haitian entrant LPR n/a MAY BE ELIGIBLE FOR: Medicaid QHP Enrollment Daniel Amina Medicaid/CHIP

Eligibility for PTC and Medicaid: Non-Expansion State
Medicaid/CHIP Premium Tax Credits Eligible? HH Income FPL* Marie No 3 $18,800 94% 95% Daniel Amina Yes Marie and Daniel are qualified immigrants, and because they entered the U.S. as Cuban/Haitian entrants, are not subject the five-year waiting period They meet the Medicaid immigration status requirement but their income is above the 30% FPL limit for parents and Florida has not expanded Medicaid, so they are ineligible. Marie and Daniel are not eligible for PTC because their income is below 100% of FPL *Medicaid currently uses the 2015 federal poverty line for determining eligibility and the Marketplace currently uses the 2014 federal poverty line for determining eligibility for premium tax credits

Part III: Concerns for Families that Include Immigrants When Applying for Health Coverage

Immigration Enforcement It’s Safe to Apply
The Affordable Care Act (ACA) includes strong protections for personally identifiable information; privacy provisions were written to encourage participation of eligible individuals in mixed-status immigrant families. Agencies can only collect, use, and disclose information that is necessary for enrollment in health coverage. The U.S. Department of Homeland Security or U.S. Immigration and Customs Enforcement (DHS/ICE) has issued guidance that information about applicants/household obtained for health insurance eligibility will not be used for civil immigration enforcement purposes. Clarification of Existing Practices Related to Certain Health Care Information English: Spanish:

Privacy and Confidentiality
The Marketplaces, Medicaid and CHIP agencies must require their employees and contractors to follow strict rules protecting privacy, including: Qualified health plans (QHP) Navigators Certified application counselors Agents Brokers Call center representatives

Discrimination Discrimination based on race, ethnicity, and national origin, including language spoken, is prohibited by Title VI of the Civil Rights Act and ACA Section 1557. Prohibition applies to all entities receiving federal financial assistance: consumer assisters, clinics, hospitals, insurers, Marketplace agencies, Medicaid and CHIP agencies, contractors, health plans, others. Applications, processes and procedures that have a chilling effect of deterring eligible immigrants from applying may violate Title VI and Sec

Protections for Non-Applicants
All Applications Should Allow Households to Designate Individuals as Non-Applicants Important protections for non-applicants: Should not be asked to disclose citizenship/immigration status. Must provide information that is relevant to the eligibility determination such as income and tax filing status, but generally cannot be required to provide information not relevant to the eligibility determination

Tips For Talking About Immigration Status
Do not ask non-applicants to disclose their citizenship or immigration status Use broad questions and share general information about immigrant eligibility to help consumers identify who may want to apply for insurance while providing other welcoming messages early in your conversation. For example: When asking questions about immigration and citizenship status of applicants: Avoid asking if individuals are “undocumented” or “not lawfully present” Instead use words like “eligible immigrant,” “eligible immigration status” or “ineligible” “ ” The Marketplace provides coverage to citizens and noncitizens who are lawfully present. Here’s a list of immigration statuses considered lawfully present. We keep your information private and safe. The application asks for some information about everyone in your family, but only a family member seeking coverage for him or herself has to answer questions about immigration or citizenship. “ ”

Requests for Social Security Numbers: Applicants
Medicaid and CHIP SSNs are generally required of Medicaid applicants Coverage cannot be denied or delayed pending issuance or verification of SSN Medicaid agencies must help individuals apply for an SSN if they are eligible and don’t have one, or if they don’t know their SSN Some applicants do not have to provide Social Security numbers (SSN), including: Newborns in process of obtaining an SSN Persons who have a religious objection Certain lawfully present immigrants who are not eligible for an SSN or can only get an SSN for a non-work purpose such as certain domestic violence survivors, trafficking survivors, asylum applicants, and others Marketplace Only applicants who have an SSN are required to provide one. General Rules About Requests for SSNs Applicants must be notified about: Whether providing their SSN is required or optional Why they are being asked for their SSN How their SSN will be used NOTE

Requests for Social Security Numbers: Non-Applicants
Medicaid and CHIP Non-applicant household members do not have to provide an SSN in Medicaid and CHIP. Marketplace Non-applicant household members should not be required to provide an SSN unless ALL of the following are true: They have a spouse or tax dependent seeking premium tax credit eligibility The non-applicant is a tax filer The non-applicant has a SSN They filed a federal tax return in the 2013 tax year However, providing an SSN, when available, may increase the likelihood that application information can be verified electronically. People who are not eligible for SSNs may use Individual Taxpayer Identification Numbers (ITINs) to file taxes, but health insurance affordability program applications should not request ITINs.

Public Charge “Public charge” is a term used by U.S. immigration officials to refer to a person who is considered primarily dependent on the government for subsistence (cash assistance) or long-term care at government expense. Generally, Medicaid, CHIP, and Marketplace subsidies are not considered in screening green card applicants (applicants to adjust to lawful permanent resident status/LPR) for public charge. Medicaid exception: long-term institutionalization Public charge is not applicable when applying for citizenship.

Part IV: Identity Proofing

Identity Proofing Required to Submit an Application Online
Online identity proofing/verification: The person completing the application (household contact) is asked to provide information Experian tries to provide customized credit-related questions for the household contact Household contact tries to answer questions if provided Telephonic identity proofing/verification: Household contacts who can’t complete the online identity proofing process, are provided a unique reference code Household contacts call the Experian Help Desk directly (language assistance is now available) Manual identity proofing/verification: Household contacts who can’t complete the identity proofing process online or over the phone, can submit copies of certain documents to prove their identity

Consumers Can Prove Identity By Mailing or Uploading
One of these: Alternatively, two of these: Driver’s license issued by state or territory School identification card Voter identification card U.S. military draft card or draft record Identification card issued by the federal, state, or local government U.S. passport or U.S. passport card Certificate of Naturalization (Form N-550 or N-570) or Certificate of U.S. Citizenship (Form N-560 or N-561) Permanent Resident Card or Alien Registration Receipt Card (Form I-551) Employment Authorization Document that contains a photograph (Form I-766) Military dependent's identification card Native American tribal document U.S. Coast Guard Merchant Mariner card Foreign passport or identification card issued by a foreign embassy or consulate that contains a photograph Birth certificate Social Security card Marriage certificate Divorce decree Employer identification card High school or college diploma (including high school equivalency diplomas) Property deed or title

People Unable to Complete the Identity Proofing/Verification
Complete the application using a paper form or over the telephone Request paper notices Use “see plans and prices” tool to browse plans Select a plan through the call center Report changes and complete renewals through the call center

Citizenship and Immigration Status Verification
Part V: Citizenship and Immigration Status Verification

How the Marketplace Verifies Citizenship
Applicant provides Social Security number(s) Applicant attests to being a U.S. citizen Healthcare.gov attempts to verify citizenship through a data match with Social Security Administration (SSA) records If citizenship can’t be verified, the applicant is asked if he is a naturalized or derived citizen* and if so, applicant is asked to provide: An alien number (also called USCIS number), and either a Naturalization Certificate number or a Certificate of Citizenship number Healthcare.gov tries to verify citizenship through data match with SAVE (Systematic Alien Verification for Entitlements) program *The term “naturalized” citizen is used to describe individuals born outside of the U.S. who become U.S. citizens after completing certain requirements and the “naturalization” process. The term “derived” citizen refers to U.S. citizens who obtain citizenship through U.S. citizen parents.

Reasons Data Matching May Be Unsuccessful
Incorrect submission of Social Security number (or no number provided) Name provided on the application does not match what is in SSA or SAVE records Data matching limitations: SSA cannot verify citizenship for many citizens who were born outside of the U.S. SAVE may not be able to immediately verify citizenship for some naturalized or derived citizens Some consumers may not have certificate numbers readily available (especially derived citizens)

Documents That Can Be Used to Prove U.S. Citizenship
Submit any one of the following documents to verify citizenship U.S. Passport Certificate of Citizenship Certificate of Naturalization State-issued enhanced driver’s license (EDL) Currently available in Michigan, New York, Vermont and Washington Document from a federally recognized Indian tribe that includes the individual’s name, the name of the tribe, and shows membership, enrollment, or affiliation with the tribe A tribal enrollment card A Certificate of Degree of Indian Blood A tribal census document Documents on tribal letterhead signed by a tribal leader NOTE: If a person does not have one of these documents, they will need two documents to prove citizenship.

If None of the Previous Documents Are Available:
Submit ONE document from EACH column (total of TWO documents) One of the following documents: AND one of the following documents: U.S. public birth certificate Consular Report of Birth Abroad (FS-240, CRBA) Certification of Report of Birth (DS-1350) Certification of Birth Abroad (FS-545) U.S. Citizen Identification Card (I-197 or the prior version I-179) Northern Mariana Card (I-873) Final adoption decree showing the person’s name and U.S. place of birth U.S. Civil Service Employment Record showing employment before June 1, 1976 Military record showing a U.S. place of birth U.S. medical record from a clinic, hospital, physician, midwife or institution showing a U.S. place of birth U.S. life, health or other insurance record showing U.S. place of birth Religious record showing U.S. place of birth recorded in the U.S. School record showing the child’s name and U.S. place of birth Federal or State census record showing U.S. citizenship or U.S. place of birth Documentation of a foreign-born adopted child who received automatic U.S. citizenship (IR3 or IH3) Document must have a photograph or other information, like name, age, race, height, weight, eye color, or address Driver's license issued by a State or Territory or ID card issued by the Federal, state, or local government School identification card U.S. military card or draft record or Military dependent’s identification card U.S. Coast Guard Merchant Mariner card Voter Registration Card A clinic, doctor, hospital, or school record, including preschool or day care records (for children under 19 years old) 2 documents containing consistent information that proves your identity, like employer IDs, high school and college diplomas, marriage certificates, divorce decrees, property deeds, or titles

How the Marketplace Verifies Immigration Status
Applicants attest to having an “eligible immigration status” Applicants submit applicable document numbers Marketplace tries to verify status through SAVE

Reasons Data Matching May Be Unsuccessful
Name does not match SAVE records Use of hyphens and apostrophes Incorrect or no submission of document numbers SAVE may not be able to verify immigration status instantly for some applicants for various reasons

Examples of Document Types
Lawful Permanent Resident / “Green Card” Employment Authorization Card Refugee Travel Document

Permanent Resident Card, “Green Card,” I-551
Lawful Permanent Resident / “Green Card” Employment Authorization Card Refugee Alien Registration Number Card Number (may be located on the back)

Employment Authorization Card (I-766)
Lawful Permanent Resident / “Green Card” Employment Authorization Card Refugee Alien Registration Number Card Number Category Code Expiration Date

Refugee Travel Document (I-571)
Lawful Permanent Resident / “Green Card” Employment Authorization Card Refugee Travel Document Alien Registration Number

Arrival/Departure Record and Notice of Action
I-94, I-94A, I-94 in foreign passport Notice of Action: I-797 I-94 number found on a customs form Notices of action are issued by the US Department of Homeland Security, U.S. Citizenship and Immigration Services (USCIS) for different purposes. Most I-797s will have either an I-94 number or an A#. I-94 Number

Immigration and Citizenship Verification Steps for the Ruiz Family
Roberto and Monica are married and have two children, Miguel and Elena Monica was born in Germany and is a derived U.S. citizen. Roberto has been a lawful permanent resident (LPR) for seven years. Miguel and Elena were born in the U.S. All family members provide Social Security numbers in the application. Monica, Miguel and Elena attest to being U.S. citizens. Monica is asked if she is a naturalized or derived citizen and she answers “yes” Monica does not have a Certificate of Citizenship, so she skips the questions asking for document numbers Roberto attests to having an eligible immigration status He provides his “alien registration number” and card number. All family members provide their social security numbers in the application and we will say they input them carefully and correctly. Monica, Miguel and Elena all attest to being US citizens. Monica is asked if she is a naturalized or derived citizen and she says yes. She is asked to provide numbers from her certificate of Citizenship and she does not have that document so she skips the question. Roberto attests to having an eligible immigration status and he provides his alien registration number and card number.

Data Matching Results Applicant: Data Match: SSA Data Match: SAVE
Monica No match Roberto N/A Miguel & Elena Match Lets see what happens in their data matching results. SSA was not able to substantiate Monica’s attestation of citizenship—remember she was born outside of the US and was born before SSA began verifying citizenship when issuing SSNs. She did not have documents numbers to provide from a Certificate of Citizenship, so she is also not matched by SAVE. Roberto is not a citizen, so no matching occurs with SSA. And although he entered all document numbers, SAVE was not able to match him instantly. Both of the children were successfully data matched by SSA.

Eligibility Results for the Ruiz Family
Eligibility determination notice (EDN) explains: All Ruiz family members are approved to buy a Marketplace plan and are awarded APTC and CSR Monica and Roberto are instructed to provide documents to prove their status within 95 days After submitting the application, the family gets an Eligibility Determination notice. Which indicates the family is eligible to enroll in Marketplace coverage with subsidies and that Monica and Roberto must send in more information before the end of a 95 day period.

Ruiz Family Gets a Warning Notice
Monica and Roberto submitted documents that were not sufficient: Monica sent in her Consular Report of Birth Abroad, but she also needs to send in a document that includes a photo or other identifying information. Roberto sent in his foreign passport, which in some cases may be used to prove lawful permanent residence, but in his case the passport did not contain the necessary information. Monica and Roberto get warning notices explaining their coverage will end if sufficient documents are not submitted. Lets say that the family did submit documents but still gets a warning notice from the Marketplace. Monica sent in her Consular Report of Birth Abroad, but she also had to send in a document that appeared on the right side of that list I showed you earlier. The second document must have something like a photo that can be used to identify her. Roberto sent in his foreign passport which is a document that was listed as a document he could send in and at times would contain information needed to prove his status, but in this case we will say his passport did not have necessary information. So both Monica and Roberto are told that they must send in documents to prove status or their coverage will end.

Monica Gets an Inconsistency Expiration Notice
Monica does not have a document from the list of options so she does not send in additional documents. Roberto sends in a copy of his Lawful Permanent Resident “Green Card.” Monica gets an “inconsistency expiration notice” that explains that her Marketplace coverage will end because she did not provide documentation to prove her citizenship. Monica does not have anything else to send, so she does not send in anything else. Roberto sends in a copy of his Permanent Resident card which clears his inconsistency. Monica gets an inconsistency expiration notice that explains her coverage will end because she did not submit enough information to prove her citizenship.

How Monica Can Regain Coverage
Monica can regain coverage if she resolves the inconsistency by sending in necessary documents After resolving the inconsistency, she can re-enroll in a Marketplace plan prospectively or retroactively with a special enrollment period. April 1 April 3 April 14 May 1 April 1st: Monica loses coverage April 3rd: She obtains a state ID with her picture. She uploads a copy to her Marketplace account April 14th: Monica’s inconsistency is resolved.  What’s next for Monica. Lets say Monica wants to re-enroll in coverage with her family. Even after coverage ends she can clear up the inconsistency. And after resolving the inconsistency she can get an SEP to re-enroll in coverage. So lets say that on April 1, Monica no longer has coverage because of the inconsistency. On April 3rd, Monica spends the day at the DMV and gets an ID issued to her and immediately uploads it to her Marketplace account. On April 14 the inconsistency is resolved. At that point, Monica can chose to re-enroll with her coverage starting on May 1 or she could select to have coverage restored retroactively to April 1 (although, she would have to pay the April premium payment in order to do that) She has the option to: Have coverage, APTC, and CSR beginning May 1, OR, have coverage, APTC, and CSR retroactive to April 1

Immigrants with Incomes Below 100% of Poverty Line
If Healthcare.gov can’t electronically verify that a lawfully present individual is eligible for Medicaid due to his immigration status, then he is assumed eligible for Medicaid based on immigration status while he has an opportunity to provide proof. As a result: If otherwise eligible for Medicaid based on income and other factors, sent to Medicaid If not otherwise eligible for Medicaid, given the opportunity to enroll in a Marketplace plan with no advance payments of the premium tax credits and cost sharing reductions If the Marketplace can instantly verify that the consumer is lawfully present but ineligible for Medicaid due to status through its SAVE data match, all is fine for these individuals—they will get the correct determination made immediately. However, if the data match can’t instantly verify they are ineligible for Medicaid due to status, then things get more complicated. The Marketplace will treat these consumers as if they were fully eligible for Medicaid based on immigration status while their immigration status is proved. That means in the person is otherwise eligible for Medicaid because of their income and other factors, the marketplace will assess or determine them eligible for Medicaid. If they don’t appear eligible for Medicaid, like perhaps a childless adult in a non-Medicaid expansion state, the marketplace will allow the consumer to enroll in a marketplace plan but with no subsidies.

Process When Sent to Medicaid
Marketplace assesses consumer eligible for Medicaid and notifies consumer of eligibility determination Case sent to state Medicaid agency for further eligibility review Medicaid agency notifies consumer that proof is needed including but not limited to immigration status If consumer sends in proof, determined ineligible for Medicaid based on status and Medicaid agency sends consumer denial notice Case referred back to Marketplace Marketplace notifies consumer to come back to the Marketplace with instructions on how to get correct eligibility determination So what happens when the Marketplace thinks the applicant is eligible for Medicaid—which by the way will happen a lot in states that have expanded Medicaid, but this can also happen in non-expansion states, for example, a parent who meet’s the 1931 coverage category in a non-expansion state would be sent to Medicaid. So what happens: Medicaid will ask the consumer to provide documents to prove their immigration status. If the consumer has no other inconsistencies, he should be provided Medicaid while he has time to send in documents and the state has time to process the document. If Medicaid determines the consumer is lawfully present but ineligible for Medicaid due to status, Medicaid will deny Medicaid eligibility and send the consumer back to Marketplace. Healthcare.gov will then send the consumer instructions steps to take to get the correct determination in their healthcare.gov account. Easy right? Consumer returns to Marketplace to update application: Indicates has been denied Medicaid and provides other needed information such as offer of MEC Correct eligibility determination for PTCs

Process When Determined Not Eligible for Medicaid or APTC
Marketplace determines consumer can enroll in coverage without APTC and notifies consumer of eligibility determination and that proof of status is needed Marketplace periodically sends targeted outreach to consumers that notifies of possible eligibility for APTC, but must turn in proof of status If consumer sends in proof, case sent to special processing center for verification of immigration status based on Medicaid rules Determined ineligible for Medicaid based on verification of status Marketplace notifies consumer to come back to the Marketplace with instructions on how to get correct eligibility determination So what happens to folks the Marketplace thinks are ineligible for Medicaid and subsidies in this group? After submitting the application, the consumer is told he is eligible to purchase a Marketplace plan without any subsidies and is told to provide proof of status. Periodically, Healthcare.gov sends people in this group notices explaining they may qualify for subsidies and to send in documents to prove status. If the consumer sends in documents, and the Marketplace determines their status makes them ineligible for Medicaid, they will send consumers a notice with instructions on how to come back to the Marketplace and take special steps to get the new eligibility determination. They will have to complete questions like the questions related to Minimal essential coverage which they would not have been asked when they first applied for coverage. And they will have to indicate they have been denied Medicaid because of their immigration status. We get that this is really complicated and difficult for consumers, and we do know that CMS is looking into this and if trying to see if it can make changes to improve this process. We will be watching that closely so stay tuned, we will let you know if we hear about developments on this. With that, I think we are going to pause for some questions. Consumer returns to Marketplace to update application: Indicates has been denied Medicaid and provides other needed information such as offer of MEC Correct eligibility determination for PTCs

Information on ACA & Immigrants HHS
Health Coverage for Immigrants – Citizenship and Immigration Status Questions - Immigration Status and the Marketplace - Coverage for Lawfully Present Immigrants (also includes Medicaid/CHIP & addressing public charge concerns) - Immigration Document Types - For Information for Immigrant Families (includes mixed-status family concerns & use and disclosure of immigration status information) - Serving Special Populations: Immigrants -

Information on ACA & Immigrants NILC Resources
Immigrants and the Affordable Care Act - and in Spanish - FAQs: The Affordable Care Act & Mixed Status Families - “Lawfully Present” Individuals Eligible under the Affordable Care Act - Typical Documents Used by Lawfully Present Immigrants - FAQs: Exclusion of Youth Granted “Deferred Action for Childhood Arrivals” from Affordable Health Care - Immigrants, Taxes, and the ACA – Immigrants and Exemptions from the ACA Individual Mandate – DACAmented and Undocumented Immigrants and the Obamacare Tax Penalty – and in Spanish - A Quick Guide to Immigrant Eligibility for ACA and Key Federal Means-tested Programs - Sponsored Immigrants & Benefits - Federal Guidance on Public Charge: When Is it Safe to Use Public Benefits? - Maps of Health Coverage for Immigrant Children and Health Coverage for Pregnant Women - Medical Assistance Programs for Immigrants in Various States -

For more information and resources, please visit:
Contact Information Jenny Rejeske, Health Policy Analyst, National Immigration Law Center: Shelby Gonzales, Senior Health Policy Analyst, Center on Budget and Policy Priorities: For complicated cases or assistance with appeals, Florida Legal Services can help or can connect you to local legal services/legal aid offices: Miriam Harmatz, Florida Legal Services: Charlotte Cassel, Florida Legal Services: For more information and resources, please visit:

Overview of Immigrant Eligibility Policies and Enrollment Processes for Health Insurance Affordability Programs Presented in Partnership by the National.

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Overview of Immigrant Eligibility Policies and Enrollment Processes for Health Insurance Affordability Programs Presented in Partnership by the National.

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Presentation on theme: "Overview of Immigrant Eligibility Policies and Enrollment Processes for Health Insurance Affordability Programs Presented in Partnership by the National."— Presentation transcript:

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