Immigrant eligibility for care and coverage in the ACA era Joel Diringer, JD, MPH February Funded by:

Definitions  “Lawfully present” 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 2

“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)  May qualify for full-scope Medicaid (Medi-Cal)  Are subject to the individual mandate 3

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) 4

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. Supreme Court decision expected in June

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 6

Undocumented immigrants  Medi-Cal coverage  Restricted/Emergency Medi-Cal for emergency services and pregnancy  Full-scope coverage for all children regardless of immigration status starting May 2016  Sign up now!  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. 7

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. 8

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).  While undocumented persons are exempt from the individual mandate, they are subject to the tax penalty for not covering those subject to individual mandate 9

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.  procedures/public-charge procedures/public-charge 10

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. 11

Additional resources  QUESTIONS? 12

13 Joel Diringer, JD, MPH Diringer and Associates 2475 Johnson Avenue San Luis Obispo, CA