1. Immigrant Coverage Options Kyle Fisher kfisher@phlp.org November 2015

2. Session Topics 1. Medicaid & “Qualified” status  The “5 year bar”  GA-related Medical Assistance 2. “Lawfully Present” 3. Marketplace Coverage & Subsidies  For Immigrants ineligible for Medicaid 4. Emergency Medical Assistance 5. Practice Tips 2

3. Medicaid Basics Four criteria: Residency Category Income Limits Immigration Status 3

4. Immigration Status Overview For Medicaid – two standards: “Lawfully Present”  Standard for:  Children  Pregnant women “Qualified”  Plus five year waiting period for most immigrants  More narrow than “lawfully present”  Standard for:  Adults 4

5. Medicaid Eligibility 3-step analysis for each person 1) What category does the person fit in? 2) What is the person’s household size? 3) Is the person under the income limit for that category and household size? 4 th step for immigrants 1) What is the person’s immigration status and does it meet the relevant Medicaid standard? 5

6. & THE “5 YEAR BAR” “Qualified” Immigrants 6

7. Immigration Status “Qualified Alien”  More narrow than “lawfully present”  Medicaid Standard for:  Adults (unless pregnant)  Plus five year waiting period  Depending on the status, may be subject to a “5 year bar”  Have to be in qualified status for 5 years before eligible  See Medical Assistance Elig. Handbook 322, Appendix A 7

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9. 5 year bar What is the 5-year bar? A waiting period that runs from date the person obtains “qualified” status Does not apply to certain immigration categories (generally humanitarian): Refugees & Asylees (even if later become LPR) Persons granted withholding of deportation/removal Cuban/Haitian entrants Iraqi or Afghan special immigration status U.S. veterans or active duty military, spouses, or children 9

10. Example 1 10 Gary has been in the U.S. with LPR status (as an asylee) since 2008. He petitioned for a green card for his wife Nadia, who entered the country in 2011. They earn $19,000/yr (120% FPL ). Does either meet Medicaid’s immigration status standard? Immigration Status Analysis Medicaid- eligible? Qualified? Subject 5 year bar? Satisfy 5 year bar? Gary Yes Nadia No (but HC.gov)

11. GA-related Medical Assistance For very low-income immigrants subject to the ‘5 year bar’ and still in waiting period. This is state-funded MA that covers about 4,000 immigrants. GA/MA has no 5 year bar. Category: 1. Disability  Employability Assessment Form– Box 1, 2, or 3 2. Health-Sustaining Medications form, or 3. Age 59+ 11

12. GA/MA Income Limits GA-related MA (if disability/need for Rx) Income limits vary slightly by region, see MAEH 368 Appendix A GA-related MA (if age 59+) 12 HouseholdIncome Limit (monthly) Resource Limit HH of 1 $205$250 HH of 2 $316$1000 Household SizeIncome Limit (6 months) Resource Limit HH of 1$2,550$2,400 HH of 2$2,650$3,200

13. Example 2 13 Meena seeks insurance for her elderly parents (age 69 and 74), who recently arrived from India and have green cards. Her mother has Parkinson’s; her father has mobility issues. They have no income, some savings ($5,000), and are supported by their adult children. Immigration Status Analysis Coverage Options Qualified? Subject 5 year bar? Satisfy 5 year bar? Meena’s parents GA/MA (if reduce savings; over age 59, no income) HC.gov + subsidies another option

14. CHILDREN & PREGNANT WOMEN “Lawfully Present” 14

15. Lawfully Present “Lawfully Present”  Legal term of art  Medicaid Standard for:  Pregnant women  Children Under age 21  Marketplace standard for all enrollees  Does not include DACA status https://www.healthcare.gov/immigration-status-and-the-marketplace/ 15

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18. FOR IMMIGRANTS NOT ELIGIBLE FOR MEDICAID HealthCare.gov 18

19. HealthCare.gov Special rule for immigrants who do not qualify for Medicaid because of immigration status  No income floor for PTC - Income: 0 - 400% FPL To qualify for premium tax credits Normally an income “floor”:  Income: 138 - 400% FPL 19 1 person2 people3 people Adults 138% poverty $16,248$21,984$27,310

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21. HC.gov Who does this affect (among the <138% FPL)? “Qualified” immigrants not meeting the 5 year bar Lawfully present immigrants who are not qualified May need to show a Medicaid denial notice  Otherwise HC.gov screens as Medicaid eligible For very low-income “qualified” immigrants inside 5 yrs  Option:  1) GA-related MA, or  2) Marketplace coverage & subsidies 21

22. Example 3 22 Gary has been in the U.S. with LPR status (lottery) since 2011. He has petitioned for a green card for his pregnant wife Nadia, who lives with him. They earn $19,000 annually (120% FPL). Immigration Status Analysis Coverage Option Qualified? Subject 5 year bar? Satisfy 5 year bar? Lawfully present? Gary HC.gov Nadia Medicaid

23. Example 4 23 Tomas and Ana, and their five year old daughter Sofia, survived an earthquake and are here under Temporary Protected Status. They have no income. Immigration Status Analysis Coverage Option Qualified? Subject 5 year bar? Satisfy 5 year bar? Lawfully present? Tomas HC.gov Ana HC.gov Sofia Medicaid

24. Emergency Medical Assistance 24

25. EMA Emergency Medical Assistance  no immigration status required  must be otherwise eligible (meet category & income req.)  limited to time period of the emergency condition Definition:  An emergency medical condition is a medical condition with acute symptoms of such severity including severe pain, that without immediate attention, the result may be:  The patient’s health is in serious jeopardy.  Serious impairment to bodily functions.  Serious dysfunction of any body organ or part.(see MAEH 322) 25

26. EMA Emergency Medical Assistance  Covers labor & delivery  Covers prenatal care only if high-risk pregnancy  Can go backwards to cover ER visit/procedure Requires specific start and end dates  In general, shorter periods more likely to be approved Emergency medical condition  Application should be processed within 5 days  See MAEH 303.13 26

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28. HELPING IMMIGRANTS APPLY FOR MEDICAID Tips 28

29. Verification Medicaid and CHIP use “SAVE” system through Department of Homeland Security to verify immigration status  Only used to verify status for benefits eligibility  Not always verified in real time DHS may still request documentation of status  Type of document will depends on immigration status  Caseworkers may need to be educated, if no SSN  See MAEH 322, Appendixes A and B 29

30. Mixed Households Individuals can be listed as a non-applicant SSN and information on immigration status  not required for non-applicants  Especially important for ineligible parents applying for their eligible children  Required to include non-eligible household members on the application (& relevant info: income, tax filing status, etc) SSN generally required for applicants  Unless immigration status does not make eligible for SSN  Or applying for EMA only 30

31. Mixed Households 31

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33. How to Apply for Medicaid Online:COMPASS HealthCare.gov (likely slower) By phone:866-550-4355 By mail:paper application In person:@ County Assistance Office When:anytime 33

34. Resources Medical Assistance Eligibility Handbook  Chapter 322 – Citizen/Noncitizen  http://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/index.htm http://services.dpw.state.pa.us/oimpolicymanuals/manuals/bop/ma/index.htm HealthCare.gov  https://www.healthcare.gov/immigrants/immigration-status/ https://www.healthcare.gov/immigrants/immigration-status/ Center on Budget and Policy Priorities – ‘Beyond the Basics’  http://www.healthreformbeyondthebasics.org/ http://www.healthreformbeyondthebasics.org/ National Immigration Law Center  http://nilc.org/immigrantshcr.html http://nilc.org/immigrantshcr.html PHLP manual – Health Care for Immigrants  http://www.phlp.org/wp-content/uploads/2015/01/Immigrant-Health-Care-Manual-For- Advocates-2015.pdf http://www.phlp.org/wp-content/uploads/2015/01/Immigrant-Health-Care-Manual-For- Advocates-2015.pdf PHLP Helpline: 1-800-274-3258  Kfisher@phlp.org Kfisher@phlp.org 34