1. Health Action 2016 Improving Immigrant Health: Marketplace Challenges and Covering the Undocumented

6. Improving Immigrant Health Marketplace Challenges Shelby Tania Gonzales February 5, 2016

7. Application Process Challenges for Families that include Immigrants 6 Face challenges all may encounter: →Account set up requirements →Verification of income →Navigating potential other MEC →Call center And unique challenges: →Authentication of identity (a.k.a. ID Proofing) →Verification of citizenship and immigration status →Proving ineligible for Medicaid based on immigration status →Language access

8. Identity Proofing Does not fulfill an eligibility requirement Relies heavily on data from credit histories Some groups are disproportionately affected: →Young people →People who have experienced ID theft →People with very low incomes →Immigrants 7

9. Identity Proofing Steps in the HC.gov 8 Online Help DeskSend in Proof ! If ID proofing is not successfully completed, consumers: –Can’t submit applications online or select plans online –Can’t renew or report changes online –Must use telephone or paper to submit applications –Must use telephone to renew coverage, select plans and report changes

10. All Consumers Should Have the Option to Use Online Features Allow all applicants to submit online applications before completing remote identity proofing (RIDP) Expand data sources used in the RIDP process Engage assisters in the RIDP process Eliminate unnecessary steps in the process like calling the help desk Expand list of acceptable identity documents Use documents sent in for immigration and citizenship to clear inconsistencies Preventing the RIDP process from causing applicants to miss enrollment deadlines Monitor and publish RIDP performance data Reassessing appropriate security approaches given current knowledge about risks 9 For more info, see “Remote Identity Proofing: Impacts on Access to Health Insurance”: www.cbpp.org/research/remote-identity-proofing-impacts-on-access-to-health-insurance www.cbpp.org/research/remote-identity-proofing-impacts-on-access-to-health-insurance ?

11. Citizenship and immigration status of applicants must be verified The application should try to verify status electronically Temporary benefits should be provided while status is verified 10 Citizenship and Immigration Status Verification

12. Bumps in the Road to Verification Errors in submission of document numbers or no number provided →Entering the correct numbers may be difficult Name, date of birth and document numbers provided on the application do not match what is in SSA or SAVE records Data match limitations: →SSA can’t verify citizenship for many citizens who were born outside of the U.S. →SAVE may not be able to verify immigration status instantly for some applicants due to system limitations 11

13. Improvements Needed in the Verification Process More training for assisters, call center operators and eligibility works finding and inputting correct numbers More online help for consumers in identifying the correct numbers to provide Maximize use of electronic steps in verifying status using SAVE Ensure temporary benefits are provided while status is being verified Clearer notices about documents needed to complete the verification. 12 For more info, see webinar “Preventing and Resolving Data-Matching Issues in the FFM”: www.healthreformbeyondthebasics.org/webinar-preventing-and-resolving-data-matching-issues-in-the-ffm www.healthreformbeyondthebasics.org/webinar-preventing-and-resolving-data-matching-issues-in-the-ffm ?

14. Proving Ineligible for Medicaid Based on Immigration Status For people with income that would potentially qualify them for Medicaid, the Marketplace must verify that applicants are ineligible for Medicaid based on their immigration status before determining their eligibility for subsidies. If can’t electronically status through SAVE instantly, status must be verified by the Marketplace through a manual document review or by the Medicaid or CHIP agency AS A RESULT: 13 If income is below the poverty line and not otherwise eligible for Medicaid (appears to be in the coverage gap): →given the opportunity to enroll in a Marketplace plan with no advance payments of the premium tax credits or cost-sharing reductions If otherwise eligible for Medicaid based on income and all other factors: →sent to Medicaid

15. Improvements Needed to Get an Accurate Decision During Inconsistency Period Allow consumers the option to attest to a specific immigration status Take all steps to improve verification processing highlighted on slide 7 Improve notices so consumers understand what is happening and are motivated to send in documents 14 For more on process barriers, see “Key Facts: Helping Families That Include Immigrants Apply for Health Coverage”: http://www.healthreformbeyondthebasics.org/key-facts-application-process-families-that-include-immigrants/ http://www.healthreformbeyondthebasics.org/key-facts-application-process-families-that-include-immigrants/ ?

16. Additional Resources Key Facts: Immigrant Eligibility for Health Insurance Affordability Programs: http://www.healthreformbeyondthebasics.org/key-facts- immigrant-eligibility-for-coverage-programs/http://www.healthreformbeyondthebasics.org/key-facts- immigrant-eligibility-for-coverage-programs/ Webinar: Eligibility and Enrollment Process for Families that Include Immigrants: http://www.healthreformbeyondthebasics.org/cbpp-webinar- immigrant-eligibility-and-enrollment-process/http://www.healthreformbeyondthebasics.org/cbpp-webinar- immigrant-eligibility-and-enrollment-process/ 15

17. Shelby Tania Gonzales gonzales@cbpp.org www.cbpp.org 202.408.1080

18. Improving Immigrant Health: Marketplace Challenges and Covering the Undocumented – California’s Fight for Health for All Ronald Coleman Government Affairs Manager California Immigrant Policy Families USA: Health Action 2016 February 5, 2016

19. Founded in 1996, CIPC is a non-partisan, non-profit statewide organization that seeks to inform public debate and policy decisions on issues affecting the state’s immigrants and their families in order to improve the quality of life for all Californians. CIPC engages in policy advocacy, and also provides technical assistance, training and education on immigrant issues.

20. Undocumented Immigrants in the U.S. ￭ 11 million undocumented immigrants nationwide ￭ 2.6 million are in the state of CA ￭ Prior to Admin. Relief: Deportation Raids ￭ > 2M deportations under the President Obama Administration ￭ Fear and mistrust and mistrust in communities

21. The Path to Health for All: California Takes Several Steps to Integrate Immigrants Driver’s Licenses – AB 60 (Alejo), 2013 TRUST Act – AB 4 (Ammiano), 2013 Professional Licenses SB 1159 (Lara), 2014 and State Bar Dream Act AB 1024 (Gonzalez, 2013) Protections for Workers – Anti-Retaliation, E-Verify Full Scope Medi-Cal for All Low-Income Lawfully Present Immigrants; Transitioning to Covered California Soon Healthcare for All Kids Regardless of Status – Begins May 16 th 2016

22. What Has California Done to Ensure Access to Healthcare for Immigrants? What more should be done?

23. California’s Immigrants and the Affordable Care Act  Eligibility o All lawfully present immigrants are eligible for federal coverage under the ACA (Deferred Action for Childhood Arrivals recipients are not eligible) o Undocumented immigrants are not eligible to purchase coverage through state’s exchange Covered CA or access full scope Medi-Cal if low income o CALIFORNIA: covers all low-income lawfully present immigrants who are designated as PRUCOLs or Permanently Residing Under Color of Law. This includes DACA/DAPA folks in CA’s Medi-Cal program

24. DACA/DAPA Recipients & Medi-Cal Deferred Action for Childhood Arrivals (DACA) Program passed in June 2012 President Obama’s announcement to excluded DACA’s from the ACA PRUCOL eligibility category  PRUCOLs are eligible for many safety net programs in California, including full scope Medi-Cal.  Therefore, DA recipients are eligible for full scope Medi- Cal, if they meet the income requirement of 138% of the FPL

25. Administrative Relief Impact on California 2012 – DACA – Approximately 300,000 Californians 2014 – Approximately 1.3 Million Eligible with Expanded DACA and DAPA Protection from Deportation – Work Permit TX Lawsuit Recent DOJ appeal; SCOTUS to hear case Timelines Expectations Implications for California

26. Undocumented Californians and Health Access The Affordable Care Act (ACA) has expanded health coverage to millions of Californians but many are purposefully, discriminatorily, and explicitly excluded:  Remaining Uninsured  UC Berkeley Labor Center study- After the full implementation of the ACA, there will be 2.7-3.4 million Californians who will remain uninsured  About 1.2 million will be undocumented Californians  Nearly 10% of the state’s workforce; 130 Billion in GDP – bigger than GDP of neighboring Nevada  3.2 Billion in Tax Revenue  Access “Band Aid” Care-Patchwork of coverage for the undocumented. o Some counties offer coverage, other counties don’t offer any coverage, and some offer limited scope/duration coverage. o Emergency and charity care

27. California’s Safety Net Emergency Rooms: However, only to stabilize emergencies; subsequently Big bills and debt Private providers: clinics, hospital charity care Counties as the final safety-net option State-Funded Programs

28. CA Programs Available Regardless of Status  Emergency Medi-Cal  Prenatal care (Medi-Cal)  Access for Infants and Mothers (AIM)  Long-term care  Early Breast Cancer Detection  Breast and Cervical Cancer Treatment  California Children’s Services (CCS)  Children’s Health Initiatives  Health Programs in some counties (Healthy SF, Healthy Way LA Unmatched)  Community clinics  Child Health and Disability Prevention Program (CHDP) and CHDP “Gateway”  Family PACT  Minor consent services  Mental health services  Regional Center Services  Women Infants and Children (WIC)  School lunch and breakfast

29. Progress for County Safety-Net Programs There is a trend toward expanding access to the undocumented: Sacramento, Contra Costa, Monterey, and 35 rural counties in CMSP expanded their eligibility, including offering a limited benefit to include the undocumented. Fresno, after suing to not serve the undocumented, secured a program to fill a gap in specialty care for the undocumented. Some counties are enhancing their safety-net in a smarter way, with programs like My Health LA and Healthy SF. The proposed Medi-Cal Section 1115 Waiver seeks more flexibility with DSH and Safety-Net Care Pool (SNCP) funds to create new financial incentives & imperatives for public hospital counties to provide preventive & primary care services, and medical homes and coverage-like services, to the remaining uninsured. One year of SNCP funding is committed, but other years of funding likely through the waiver. All of these efforts are bridges to a statewide solution.

31. What type of care do immigrants receive?

34. HEALTH4ALL

36. Why is Health4All important? Though the state provides health care services through programs with limited scope or duration, and some counties provide coverage regardless of immigration status, it is not enough. o Health Care system works better when everyone participates o Emergency room treatment is expensive o Everyone deserves comprehensive and adequate care o Healthy Parents, Thriving Families o Boost Enrollment o Health is a Human Right

37. Pro-Immigrant Investments in California’s 2015-2016 Budget The 2015-2016 state budget included exciting and historic package of investments that will help lift up our immigrant communities.  SB 75 – Budget Trailer Bill – Health for All Kids: $40 Million in 2015- 2016; $145M proposed in 2016-2017 for all kids to be covered in full- scope Medi-Cal no sooner than May 1 st – Target Date: May 16  One California: $15M investment in a newly created state-funded program to support grants to community based and legal services organizations who are engaged in education, outreach, or legal support to immigrants seeking administrative relief and legal permanent residents seeking naturalization -- $15 M proposed in 2016-2017

38. California’s #Health4All Effort  Original proposal introduced by Senator Ricardo Lara in 2014 as SB 1005 – “Equitable Access for Immigrants” – Held in Appropriations  Re-introduced in December 2014 as SB 4 by Senator Ricardo Lara (cutting costs) – 1332 waiver discussions with Medi-Cal Expansion  SB 75: Legislature invests/ Governor approves healthcare for all kids as part of the 2015-2016 budget  Modified version of SB 4 is signed to ensure that undocumented children have seamless access to quality and affordable healthcare if they are currently enrolled in Restricted Scope Medi-Cal – “Lift and Shift” – 1332 Waiver amended into SB 10  SB 10 awaits action in the Assembly: Undocumented Adults in Medi-Cal and 1332 Waiver

39. SB 4- Building Blocks Towards Health4All  Undocumented children who will be eligible for full scope Medi-Cal will automatically be transferred from restricted scope into the comprehensive program immediately when the program begins  Children with serious medical conditions that require specialty care, who are being newly enrolled in the program, will be properly evaluated and referred  What this Means: ENCOURAGING PARENTS TO ENROLL CHILDREN IN EMERGENCY “Restricted-Scope” MEDI-CAL today

40. Next Steps on Health4All  SB 10 – Legislation and Budget – Any Allocation Would Likely Happen in the Budget, but there is a bill!  Currently in California Assembly  Seeks to allow undocumented adults to receive comprehensive Medi-Cal, if funding is made available.  Allow all Californians, regardless of immigration status, to purchase coverage through Covered California with their own money by requiring the state to apply for a federal Section 1332 waiver (a formal request to the federal government).Section 1332 waiver  County Efforts Continue

41. Budgetary Challenges to Next Steps Fiscally Prudent Governor Expiration of Prop 30 and 2018-2019 Projected Deficits HHS Budget: General Trend on Restorations, MCO Tax Discussions, and Other Priorities

42. What can you do?  If in CA: Outreach Fairs to Enroll Children in Restricted Scope Medi-Cal  Town Halls in Your Communities to Lift Up importance of Health for All  If Ripe, Start An Effort in Your Community to Create, Expand, Support State Effort, etc.  Participate in advocacy visits to educate policymakers at the county or state level  Join community actions, town halls, information sessions  Share and Collect constituent stories  Share information on social media #Health4All

43. Ronald Coleman Government Affairs Manager California Immigrant Policy Center Los Angeles I Oakland I Sacramento rcoleman@caimmigrant.org

44. N Y L P I Proprietary & Confidential © New York Lawyers for the Public Interest 43 Improving Immigrant Health in New York: Strategies for expanding access Laura F. Redman, Esq. Director, Health Justice Program New York Lawyers for the Public Interes t

45. N Y L P I Proprietary & Confidential © New York Lawyers for the Public Interest 44 About NYLPI New York Lawyers for the Public Interest: non-profit organization that uses a community lawyering model to serve low-income communities of color Health Justice Program: brings a racial justice and immigrant rights focus to health care advocacy in New York City and State

46. N Y L P I Proprietary & Confidential © New York Lawyers for the Public Interest 45 Expanding Access to Healthcare in NY Marketplace Language Access –NYLPI’s Secret Shopper Study NYS Medicaid coverage for immigrants NYC Direct Access Pilot Program State Level Advocacy –Organ Transplant Coverage –Coverage 4 All campaign

47. N Y L P I Proprietary & Confidential © New York Lawyers for the Public Interest 46 Testing Language Access on the Marketplace NYLPI’s telephone monitoring of Marketplace HelpLine during Open Enrollment Developed survey tool, including caller profile and script with targeted questions Qualified interpreters carried out 3 rounds of surveys in top 5 languages Results shared with State Marketplace: Changes made in response to problems identified Shared with contracted training agency, incorporating comments

48. N Y L P I Proprietary & Confidential © New York Lawyers for the Public Interest 47 Immigrant Eligibility for Medicaid in NYS Lawful Permanent Residents within the 5 year bar Individuals who have been granted Deferred Action for Childhood Arrivals (DACA) Individuals who are considered P.R.U.C.O.L Including: immigrants who have “applied for or otherwise requested a particular immigration status or relief from removal and are awaiting the federal immigration agency’s decision” 08OHP/INF-4 Children under 19 (CHP) and Pregnant Women

49. N Y L P I Proprietary & Confidential © New York Lawyers for the Public Interest 48 Comprehensive immigration and health phone screening NYLPI provides immigration representation or other relevant support Once client is PRUCOL, NYLPI will refer to a Navigator to enroll in Medicaid Overview of NYLPI’s UndocuCare Program Medicaid = Better access to healthcare

50. N Y L P I Proprietary & Confidential © New York Lawyers for the Public Interest 49 Filling in the Gaps NYC Mayor’s Task Force on Immigrant Health Care Access –RESULT: NYC Direct Access Pilot Program State-based Advocacy –Organ Transplant Coverage –Coverage4 All Campaign

51. N Y L P I Proprietary & Confidential © New York Lawyers for the Public Interest 50 Mayor’s Task Force on Immigrant Health Care Access Purpose: To identify barriers and recommend steps City can take to help immigrants overcome them Working Groups: Care and Coverage, General Barriers, Language Access, and Data Gaps Result: Report with recommendations –Direct Access Program pilot –Expand cultural and linguistic competency –Conduct public education and outreach –Increase access to high-quality medical interpretation

52. N Y L P I Proprietary & Confidential © New York Lawyers for the Public Interest 51 NYC Direct Access Pilot Program 1000 person pilot project Coordinated care through City hospital clinics NOT insurance coverage Coverage for primary care, preventative, and certain specialist care Hope to see expanded city-wide

53. N Y L P I Proprietary & Confidential © New York Lawyers for the Public Interest 52 Organ Transplant Advocacy In NYS, over 1000 undocumented immigrants receive dialysis for kidney failure through EM NYLPI economic study showing cost savings to State to cover kidney transplants over dialysis –$80 million over 10 years –Saving kicks in after 2 years Following Illinois lead, advocacy to cover kidney transplants through Emergency Medicaid funds – State legislation proposed in October 2014

54. N Y L P I Proprietary & Confidential © New York Lawyers for the Public Interest 53 Coverage 4 All Campaign Statewide campaign to provide health coverage for undocumented immigrants Economic analysis of different coverage schemes: take up and cost Strategize about discrete portion of population versus entire population Moral, fairness, and economic arguments

55. N Y L P I Proprietary & Confidential © New York Lawyers for the Public Interest 54 Questions? Laura F. Redman Director, Health Justice Program lredman@nylpi.org NYLPI Phone: 212-244-4664