1. Welcome! 1 The In’s and Out’s of Immigration and Medicaid

2. June 30, 2015 2 Health Insurance for Michigan’s Immigrant Families Angel Padilla National Immigration Law Center (NILC) Sonya Schwartz Georgetown University Center for Children and Families

3. What We Will Cover 3 Immigrant Eligibility for Medicaid and Children’s Health Insurance Program (CHIP), and Marketplace Coverage Barriers and Fears Immigrant Face When Applying for Coverage and How to Support Them Two Scenarios to Test Your Knowledge Brief discussion about how to appropriately encourage immigrant families to apply for coverage Note: We will stop for brief Q&A after each section

4. Immigrant Eligibility: Insurance Affordability Programs Different rules for different programs Different rules for family members with different immigration statuses 4

5. Eligibility for Citizens in Immigrant Families 5 Who are the citizens in immigrant families?  Native-born: All family members born in the U.S. 89% of kids in immigrant families are citizens!  Naturalized: All family members who came to the U.S. as immigrants and became citizens after arriving. Eligibility for what? Citizens are eligible for everything a citizen in an all-citizen family is eligible for!

6. Immigrant Eligibility Rules for Medicaid and CHIP The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, often referred to as “Welfare Reform,” created new categories of immigrants for benefits eligibility purposes: “Qualified Immigrants” v. “Not-Qualified Immigrants” (discussed shortly) As a result, PRWORA excluded immigrants from both groups from eligibility for many programs, with few exceptions. 6

7. Immigrant Eligibility Rules for Medicaid and 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 (e.g. lawful permanent residents or “green card holders”)  "Qualified" immigrants exempt from the 5-year waiting period (e.g. refugees, asylees, Cuban/Haitian entrants, trafficking survivors, and veteran families) States have some flexibility to vary from certain federal rules as defined by federal statute 7

8. Immigrant Eligibility for Medicaid & MIChild: “Qualified Immigrants” 8 “Qualified” Immigrants Include  Lawful Permanent Residents (LPRs/”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  Persons granted withholding of deportation/removal

9. Exceptions to General Rule (must be in “qualified status” and must wait five years or more)* Humanitarian groups of “qualified” immigrants (e.g. refugees, asylees, Cuban/Haitian entrants, trafficking survivors, and veteran families) do not have to wait five years in status Pregnant women regardless of immigration status can receive prenatal care through Maternity Outpatient Medical Services (MOMS) Individuals with emergency conditions can receive treatment for emergency regardless of immigration status through Emergency Medicaid * All must meet income and other eligibility rules for programs as well. Note: ICHIA (CHIPRA §214) provides an option for states to cover “lawfully residing” kids and pregnant women without a waiting period, but Michigan has not yet enacted this for MIChild. 9

10. Not-qualified Immigrants EVERYONE ELSE Any immigrant whose status is not on the “qualified” list is “not qualified,” even if work-authorized. NOT eligible for Medicaid (except emergency services and MOMS), MIChild, or other public programs  See exceptions in previous slide 10

11. Programs Available to ALL 11 Emergency Medicaid MOMS Immunizations FQHCs – Community Health Centers – Migrant Centers Uncompensated care, charity care, financial assistance Disaster relief -- if relief is short-term and non-cash School lunch and breakfast, food banks, WIC Mental illness and substance abuse prevention (if program is available to all regardless of income) Violence and domestic abuse prevention Shelters Additional services and health plans available in some counties

12. Immigrant Eligibility for the Marketplace & Help With Costs 12 “Lawfully present” immigrants are eligible:  Private health insurance in the Marketplaces created by the ACA  Premium tax credits and cost-sharing reductions up to 400% Federal Poverty Level (FPL), in all states  Note that APTC and CSR are available for lawfully present immigrants below 100 percent FPL who are not eligible for Medicaid or CHIP because of their immigration status  Basic Health Program Option (BHP) (0-200% FPL)  Required to have health insurance under the individual mandate Immigrants are “lawfully present” if their immigration status is listed by HHS – www.healthcare.gov/immigration-status-and-the-marketplace/ www.healthcare.gov/immigration-status-and-the-marketplace/ NOTE: Individuals granted Deferred Action for Childhood Arrivals (DACA) are not eligible for either Marketplace coverage or Medicaid/CHIP

13. ??? QUESTIONS ??? 13

14. BARRIERS TO ENROLLMENT & Tips for Breaking them Down 14

15. Concerns About applying / Enrolling Confusion about eligibility rules Privacy and confidentiality Verification and documentation  Immigration status, Social Security number (SSN), Income, Identity, State residency Public charge Hostility and discrimination Language services Tips for Working with people in immigrant families 15

16. Confusion About Eligibility Rules Emphasize that a citizen or lawfully-present child or adult will still be eligible even when other family members are not. It is safe for an ineligible family member to apply on behalf of eligible family members. Have immigrant-specific resource materials handy, in English and in multiple languages for consumers. Identify advocates in the community and Marketplace with knowledge of immigrant eligibility. Keep a record of immigration-related problems and share with MIRC and/or state and federal civil rights and health policy officials. 16

17. Privacy and Confidentiality Questions: If I go to the Medicaid agency to apply, will the agency find out that my (spouse or parent or child) is undocumented? Will the agency report my undocumented family member to immigration authorities?  Answer: The ACA and its regulations include strong protections for personally identifiable information; privacy provisions were written to encourage participation of mixed-status immigrant families.  Agencies can only collect, use and disclose information necessary for enrollment in health coverage. 10/25/13 US Department of Homeland Security guidance that information about applicants/household obtained for health insurance eligibility will not be used for civil immigration enforcement purposes. http://www.ice.gov/doclib/ero-outreach/pdf/ice-aca-memo.pdfhttp://www.ice.gov/doclib/ero-outreach/pdf/ice-aca-memo.pdf (English) http://www.ice.gov/espanol/factsheets/aca-memoSPhttp://www.ice.gov/espanol/factsheets/aca-memoSP (Spanish) 17

18. Privacy and Confidentiality The Marketplaces, Medicaid and CHIP agencies must require their employees and contractors to follow strict rules protecting privacy. Contractors include  QHP issuers  Navigators  Certified application counselors  Agents  Brokers 18

19. Protections for Non-Applicants Applications 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 19

20. Requests for Social Security Numbers Non-Applicants: People Applying for Medicaid and CHIP for other members of their family Non-applicant household members do not have to provide an SSN in Medicaid and CHIP. Applicants: People Applying for Medicaid and CHIP for themselves and/or other members of their families 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 Note: Rules are slightly different for marketplace. 20

21. Public Charge A term used by US immigration officials to refer to a person who is considered primarily dependent on the government for subsistence, as demonstrated by either receipt of cash assistance for income maintenance or institutionalization for long-term care at government expense. Where this consideration applies, an immigrant who is found to be “likely… to become a pubic charge” may be denied admission to the U.S. or lawful permanent resident status. 21

22. Public Charge Question: If I or my family member applies for Medicaid or for help with costs of coverage, will immigration authorities deny our application for a green card or citizenship? Answer: No. Medicaid, CHIP, and Marketplace subsidies are not considered in screening green card applicants for public charge.  Medicaid exception: long-term institutionalization.  Public charge is not applicable when applying for citizenship. See resource materials 22

23. 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 Applies to all entities receiving federal financial assistance: consumer assisters, clinics, hospitals, insurers, Marketplace agencies, Medicaid and CHIP agencies, contractors, HMOs, others Applications, processes and procedures that have a chilling effect -- deterring eligible immigrants from applying -- may violate Title VI and ACA Sec. 1557 23

24. Hospitality, Not Hostility Immigration enforcement authorities cannot enter into private areas of public facilities such as medical clinics without consent or a warrant. See ICE policy on Enforcement at or Focused on Sensitive Locations, which includes “hospitals” and similar locations: https://www.ice.gov/doclib/ero- outreach/pdf/10029.2-policy.pdfhttps://www.ice.gov/doclib/ero- outreach/pdf/10029.2-policy.pdf 24

25. Language Services Agencies must provide meaningful access of limited- English proficient individuals to all programs receiving federal assistance Agencies must provide free oral interpretation services and translate key documents into top languages. Assisters should learn which languages predominate Call center (1-800-318-2596) can connect to language lines for immediate interpretation into 150 languages. 25

26. 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:  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. 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” 26

27. ??? QUESTIONS ??? 27

28. Hypo: Rosina Rosina, has been a lawful permanent resident (green card holder) for four years, and she is employed by a small cleaning business. Her husband Joaquin is undocumented and her daughter Adela is a U.S. citizen. Her earnings make her and her family income-eligible for Medicaid and MIChild. What affordable health care options do Rosina, her husband Joaquin, and her daughter have? 28

29. Answers for Rosina What are Rosina’s options for affordable health care? Rosina is a “qualified” immigrant but is not eligible for Medicaid because she is subject to and has not met the five- year waiting period. Rosina is eligible for marketplace coverage with premium tax credits even though her income is below 100% FPL because she is ineligible for Medicaid due to immigration status and is lawfully present. (Remember the special rule from slide 10) If her income stays the same, she could be eligible for Medicaid with one more year of time as an LPR when she satisfies the five year waiting period. 29

30. Answers for Rosina What affordable health care options does her family have? Joaquin is undocumented and is therefore ineligible for Medicaid or Marketplace coverage. He may access community clinics, public hospitals; maybe dependent coverage under Rosina’s employer insurance. Adela is a US citizen and may be eligible for Medicaid or MIChild, depending on income cutoff. 30

31. Hypo: Seema Seema is a U.S. citizen child and is 8 years old. Both her parents came here on student visas which expired many years ago and were not renewed. Her parents both work at a family owned restaurant, but are not offered health insurance through their work. The family’s income makes them income-eligibile for MIChild What is her parents immigration status? What affordable health care options do Seema and her parents have? What would you tell her parents if they are nervous about applying for health coverage for her? 31

32. Answers for Seema What immigration status do Seema’s parents have? Because their student visas expired and were not renewed, Seema’s parents are undocumented. What affordable health care options do Seema and her parents have? Seema is a US Citizen and is eligible for MIChild. Seema’s parents are undocumented and are excluded from Medicaid and Marketplace coverage with tax credits. They can seek care at community clinics and hospitals and Emergency-only Medicaid could cover some care. They may have options outside the insurance exchange to buy health insurance although it is unlikely to be affordable for them without any subsidies. 32

33. ???Questions???? 33

34. Information on ACA & Immigrants HHS & U.S. Immigration and Customs Enforcement Resources Citizenship and Immigration Status Questions: https://www.healthcare.gov/help/citizenship-and-immigration-status- questions/ https://www.healthcare.gov/help/citizenship-and-immigration-status- questions/ Immigration Status and the Marketplace: https://www.healthcare.gov/immigrants/immigration-status/ Immigration Document Types: https://www.healthcare.gov/help/immigration-document-types/ Immigrant Families and the Marketplace: https://www.healthcare.gov/immigrants/ Clarification of Existing Practices Related to Certain Health Care Information (U.S. Department of Homeland Security, U.S. Immigration and Customs Enforcement): http://www.ice.gov/doclib/ero-outreach/pdf/ice-aca-memo.pdf Spanish: http://www.ice.gov/espanol/factsheets/aca-memoSP.htmhttp://www.ice.gov/espanol/factsheets/aca-memoSP.htm Materials in Other Languages: http://marketplace.cms.gov/outreach-and-education/other-languages.html 34

35. Information on ACA & Immigrants NILC Resources Immigrants and the Affordable Care Act: http://nilc.org/immigrantshcr.html (Spanish: http://nilc.org/immigrantshcrsp.html)http://nilc.org/immigrantshcr.html http://nilc.org/immigrantshcrsp.html Frequently Asked Questions – The Affordable Care Act & Mixed Status Families: http://nilc.org/aca_mixedstatusfams.html http://nilc.org/aca_mixedstatusfams.html “Lawfully Present” Individuals Eligible under the Affordable Care Act: http://www.nilc.org/document.html?id=809 http://www.nilc.org/document.html?id=809 Frequently Asked Questions – Exclusion of Youth Granted “Deferred Action for Childhood Arrivals” from Affordable Health Care: http://www.nilc.org/document.html?id=802http://www.nilc.org/document.html?id=802 Typical Documents Used by Lawfully Present Immigrants: http://www.nilc.org/document.html?id=35 http://www.nilc.org/document.html?id=35 Federal Guidance on Public Charge: When Is it Safe to Use Public Benefits? http://www.nilc.org/document.html?id=164 http://www.nilc.org/document.html?id=164 Sponsored Immigrants & Benefits: http://www.nilc.org/document.html?id=166http://www.nilc.org/document.html?id=166 Overview of Immigrant Eligibility for Federal Programs (see page 4 for a list of “qualified” immigrants): http://www.nilc.org/document.html?id=108http://www.nilc.org/document.html?id=108 Maps of Health Coverage for Immigrant Children and Health Coverage for Pregnant Women: http://www.nilc.org/healthcoveragemaps.html http://www.nilc.org/healthcoveragemaps.html Medical Assistance Programs for Immigrants in Various States: http://nilc.org/document.html?id=159 http://nilc.org/document.html?id=159 35

36. Information on ACA & Immigrants CCF Resources The President’s Immigration Announcement: What Do Health Policy Wonks Need to Know? http://ccf.georgetown.edu/all/presidents-immigration-announcement-health- policy-wonks-need-know/http://ccf.georgetown.edu/all/presidents-immigration-announcement-health- policy-wonks-need-know/ A Step Forward for Lawfully Present Immigrants Living in Povertyhttp://ccf.georgetown.edu/all/step-forward-covering-lawfully-present- immigrant-families-living-poverty/http://ccf.georgetown.edu/all/step-forward-covering-lawfully-present- immigrant-families-living-poverty/ The Administration’s New Welcome Mat for Immigrants: “It’s Safe to Apply” http://ccf.georgetown.edu/all/the-administrations-new-welcome-mat-for- immigrants-its-safe-to-apply/ http://ccf.georgetown.edu/all/the-administrations-new-welcome-mat-for- immigrants-its-safe-to-apply/ 36 CBPP Resources Beyond the Basics, Frequently Asked Questions: Immigrant Eligibility for Premium Tax Credits: http://www.healthreformbeyondthebasics.org/question-of-the- day/#Immigrant_Eligibility_for_Premium_Tax_Credits_and_Medicaid http://www.healthreformbeyondthebasics.org/question-of-the- day/#Immigrant_Eligibility_for_Premium_Tax_Credits_and_Medicaid Beyond the Basics, Key Facts About 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/ 36

37. Contact Information Angel Padilla, Health Policy Analyst, National Immigration Law Center –padilla@nilc.orgpadilla@nilc.org Sonya Schwartz, Research Fellow, Georgetown University Center for Children and Families -- ss3361@georgetown.edu and on Twitter @SonyaSchwartz ss3361@georgetown.edu 37 For more information and resources, please visit: www.nilc.org ccf.georgetown.edu www.healthreformbeyondthebasics.org www.cbpp.org