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Rebecca Farley

Director, Policy & Advocacy, National Council for Behavioral Health

ACA Expands Coverage for Immigrants, but Enrollment Challenges Remain

October 29, 2013 | Health Insurance Exchanges | Comments
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When the Affordable Care Act takes effect January 1, many – but not all – immigrant groups will have expanded access to insurance coverage. A new fact sheet from the Centers for Medicare and Medicaid Services (CMS) details what immigrant families, and their healthcare providers, need to know to enroll in new coverage.

Where do immigrants currently stand when it comes to health coverage?

More than half of non-U.S. citizen adults are uninsured, compared to 17 percent of adult citizens. Non-citizen adults are also less likely to have insurance through their employer, despite having similar employment rates to citizens. Likewise, immigrant children have much higher uninsured rates compared to children who are citizens. Lawfully present immigrants must wait five years in most states before becoming eligible for Medicaid. However, 22 states allow immigrant children with fewer than five years’ residency to enroll in Medicaid, and 18 states allow the same for pregnant immigrant women.

ACA coverage expansions for lawfully present immigrants:

Options available to legal immigrants under the ACA depend on the number of years they have lived in the United States.

  • Naturalized citizens and legal immigrants who have lived in the U.S. for more than five years will have the same coverage opportunities as other Americans. They may purchase insurance in the health insurance marketplaces, and those under 400 percent of the poverty level are eligible for tax credits or subsidies to offset the cost. They may also enroll in Medicaid if they meet their state’s eligibility criteria.
  • Legal immigrants who have resided in the U.S. for five years or less will be able to purchase insurance in the marketplaces and will be eligible for tax credits/subsidies. Generally, they will not be eligible to enroll in Medicaid until the end of the five-year waiting period. However, the ACA’s Maintenance of Effort (MOE) provisions require that states maintain current eligibility standards for children through Sept. 30, 2019. This means that the 22 states that opted to cover immigrant children with less than five years’ residency must continue to do so post-ACA.
Options for undocumented immigrants:

Undocumented immigrants cannot enroll in Medicaid or purchase coverage in health insurance marketplaces. The Obama Administration estimates that undocumented immigrants will make up 25 percent of the uninsured after ACA implementation. Their access to care will depend on the ability and willingness of safety net providers to serve them.

Issues for mixed-status families:

Because insurance status may pose a barrier to enrollment in families where one or more members is undocumented, CMS notes that family members who apply for health coverage on behalf of an eligible family member will not be asked about their own immigration status. The health insurance marketplaces and state Medicaid/CHIP agencies cannot ask applicants to provide immigration status information about any family or household member who is not applying for coverage.

Strategies for maximizing enrollment among immigrant groups:

Useful enrollment strategies include translation services, application assisters, electronic enrollment options, targeted outreach efforts, and wide dissemination of information to assuage fears that enrollment could be affected by a family member’s immigration status.

As behavioral health and other healthcare safety net providers strive to enroll their clients and others in their community in care, understanding the options and limitations for immigrants is pivotal to improving their health coverage and health outcomes. For more resources on enrollment best practices, visit