Immigrant Eligibility for Health Benefits: Federal Action and State Laws in 2005-2006

January 2007

Background

The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), enacted in 1996, restricted eligibility for Medicaid, and later SCHIP, for many legal immigrants. In short, newly-arriving immigrants are now ineligible for these programs during their first five years in the United States. Immigrants residing in the U.S. before August 22, 1996, or “pre-enactment” immigrants, are eligible for SCHIP, and at state option, for Medicaid, and states receive federal funding for this cohort. Most states (except Wyoming) provide Medicaid and all states provide TANF and SCHIP to pre-enactment qualified immigrants. For a review of the welfare reform bill and current eligibility requirements, please see the Appendix.

States’ response to post-enactment immigrants who are now ineligible for federal benefits have varied. Some states provide benefits, using state dollars only, to all post-enactment qualified immigrants while other states provide benefits to certain ‘vulnerable’ subgroups of qualified immigrants (children and pregnant women). As of 2006¹, 22 states provided Medicaid, 18 provided SCHIP and 22 provided TANF to at least some post-enactment qualified immigrants who are ineligible for federal benefits.

Federal Rules on Medicaid Documentation

The 2005 Deficit Reduction Act (DRA)² created a new federal mandate requiring all persons applying for or renewing their Medicaid coverage must provide proof of their U.S. citizenship and identity in order to receive benefits. Prior to this rule, applicants were allowed to attest, under penalty of law, to their citizenship (eligible non-citizens had to undergo further requirements). Although the DRA does not alter eligibility criteria for Medicaid (immigration status requirements themselves did not change), citizenship documentation requirements do make proving eligibility more difficult³. Federal matching funds are not available to states for benefit recipients who have not adequately proven U.S. citizenship.

2006 State Legislation

In 2006, eight bills in six states related to public health benefits and immigrants were enacted. Arizona moved to comply with the 2005 Deficit Reduction Act (DRA); California affirmed that localities can provide health care to immigrants made ineligible under the federal welfare law; Colorado added verification of lawful presence for adult applicants and requires agencies to continue identification, prevention and treatment of communicable diseases regardless of immigrant status; Maine defined residency criteria for individual health insurance; Maryland restored eligibility for certain legal immigrant children and pregnant women; and Rhode Island grandfathered certain unauthorized immigrant children into the state Medicaid program.

Arizona HB 2448 made changes to Arizona’s Medicaid Program (Arizona Health Care Cost Containment System or AHCCCS) to comply with the 2005 DRA. Specifically, the law requires verification of applicants’ citizenship or qualified alien status, whereas previously verification was only required in suspect cases. In addition, AHCCCS, in conjunction with the Department of Economic Security, is required to submit reports to the governor, state legislature, and certain other governing bodies on the number of individuals verified, the number and kind of fraudulent documents discovered, and eligibility verification measures being taken for individuals receiving cash assistance or AHCCCS benefits.

Arizona SB 1137 establishes the Comprehensive Care for the Elderly (CCE) program as an alternative service delivery model for elderly and disabled individuals who need ongoing services at a nursing facility level of care. Under the CCE model, Arizona Long Term Care System (ALTCS) managers may contract outside vendors (including primary care providers, nurses, social workers, dieticians, transportation services and other professionals) to provide medical and social services through interdisciplinary teams in a single facility. S.B. 1137 outlines eligibility requirements consistent with the DRA for both the ALTCS and the CCE programs to include U.S. citizenship or legal alien status for at least five years. The eligibility requirements mirror those in H.B. 2448.

California SB 1534 affirms that counties, cities and hospital districts, at their own discretion, can provide health care and other services to all residents (regardless of citizenship). This is in response to changes in the 1996 federal welfare law which provides that certain classes of immigrants are ineligible for defined state and local public benefits unless new state laws affirm immigrant eligibility. Existing law requires each county or city to provide aid to its indigent population not supported by other means. The law authorizes that any city, county, or hospital district can provide aid, including health care, to persons who, but for the above referred-to provision of the federal PRWORA, would meet the eligibility requirements for any program of that entity.

California SB 1569 extends eligibility for state and local public benefits, Medi-Cal health care and refugee cash assistance and employment services, to non-citizen victims of trafficking, domestic violence and other serious crimes, to the same extent as available to individuals admitted to the United States as refugees. The State Department of Social Services must adopt regulations, which may be emergency regulations, to implement these provisions no later than July 1, 2008.

Colorado HB 1023 requires all state entities to verify the lawful presence of persons 18 years or older who apply for state, local, or federal public benefits. Lawful presence does not need to be established in several cases: for any purpose where lawful presence in the US is not required by law, for emergency medical conditions (except those related to an organ transplant), for short-term emergency disaster relief, public health immunization against and treatment of communicable diseases, community level programs that do not condition assistance on the recipient’s income and are necessary for protection of life and safety, and prenatal care. Lawful presence is verified through producing a state driver’s license or ID card, a US military ID card, US coast guard merchant mariner card, or Native American tribal document and by signing of an affidavit affirming citizenship or legal status.

Colorado HB 1002 directs the Department of Public Health and Environment and the Department of Health Care Policy and Financing to administer programs and services relating to identification, prevention, and/or treatment of communicable diseases. These programs and services are to be administered to individuals regardless immigration status. Services for child immunizations, tuberculosis, HIV/AIDS and other sexually transmitted diseases are included in these provisions.

Maine LD 1734 (HP 1242) changes the definition of ‘legally domiciled,’ for purposes of individual health insurance eligibility requirements. Previous statute required persons to satisfy 3 of 4 requirements (valid driver’s license, proof of voter registration, permanent dwelling in the State, and proof of filing a resident income tax return). Under this bill, 2 of 6 criteria must be satisfied (valid passport/visa and sworn affidavit of residence are added as criteria, and a state ID card is now allowable in place of a valid driver’s license).

Maryland HB 89 restores eligibility for state Medicaid benefits (Maryland Medical Assistance Program) for post-PRWORA-enactment immigrant children and pregnant women. This bill requires that a minimum of $3 million be appropriated to provide Medicaid benefits to these immigrant groups in FY2008. This eligibility was first restricted in 2005 as part of budget cuts for FY2006 and FY2007. The law also requires a report by the Department of Health and Mental Hygiene to include a description of the immigrant health initiative, those being served, types of services provided, and potential inequities in all areas prior to 2005.

Rhode Island H 7120 (FY2007 Budget) continues payment of state Medicaid benefits (RIte Care Program) to unauthorized immigrant children who have been enrolled in the program prior to December 31, 2006. No new non-citizen children, including those lawfully present, may be enrolled in the RIte Care program after this date.

2005 State Legislation

Colorado H.B.05 1086 reinstated SSI and Medicaid eligibility for about 3500 legal immigrants who lost benefits as a result of a controversial budget cut during FY 2003. This made Colorado one of two states ever to take away Medicaid benefits from a group that had them previously. Part of the funding for the cost to the state was appropriated from Colorado’s new tobacco tax, which is expected to generate $175 million in extra revenue annually.

Maine L.D. 37/S.P. 17 created a demonstration project for mental health and substance abuse services for refugees. Enacted as an emergency measure, it directs the Department of Health and Human Services to seek federal funding to provide substance abuse and mental health programs to immigrants and refugees.

Washington H.B. 1441 reinstated SCHIP eligibility to immigrant children (including unauthorized immigrant children and legal immigrant children eligible but for the five-year federal bar) with the goal of covering all children by 2010. Children’s Health Program is available to non-citizen children living below 100% of the Federal Poverty Level.

Virginia H.B. 1798/S.B. 1143 prohibited unauthorized immigrants from receiving state or local public benefits. It is unknown what proportion of public spending is used by unauthorized immigrants.

Note: The state legislative database search identifies bills with the terms immigrant, refugee, non-citizen or alien; legislation that refers to eligibility, access, or coverage more generally may affect immigrants, but is not captured by this search. Please send corrections to Dirk Hegen at Dirk.Hegen@ncsl.org.

Appendix – Immigrant Eligibility Changed by Federal Welfare Reform

Previous Law:

Until 1996, eligibility requirements for lawful permanent residents (LPRs) to access public benefit programs⁴ were largely the same as for citizens. AFDC, SSI, and food stamps (but not Medicaid) required that for the first 3-5 years, depending on the program, an immigrant’s sponsor’s income be ‘deemed’ available for the immigrant when calculating income-eligibility for these programs. LPRs who gained legal status through the Immigration Reform and Control Act (IRCA) of 1986 were barred from federal programs for five years (unless 65 years or older, blind, disabled, a Cuban/Haitian entrant, or, for Medicaid only, a child under 18, or a pregnant woman). These LPRs were, however, eligible for state and local benefits, and IRCA set up the State Legalization Impact Assistance Grant (SLIAG) to reimburse state and local governments for expenses incurred by services rendered to these LPRs. Nonimmigrants (those in the US on temporary visas) and unauthorized aliens (other than PRUCOL aliens⁵) were barred from receiving full Medicaid benefits.

Current Law:

1996 Welfare Law (the Personal Responsibility and Work Opportunity Reconciliation Act or PRWORA) reformed the welfare system and drastically altered legal immigrants’ access to federally funded means-tested benefits.⁶ The welfare law defines “qualified” immigrants⁷—LPRs, refugees, asylees, Cuban/Haitian entrants, and certain abused immigrants—and “not qualified” immigrants—all others, including unauthorized immigrants and those lawfully present in the country on temporary (nonimmigrant) visas. Not qualified immigrants are barred from public benefits other than emergency Medicaid.

The 1996 Welfare Law divided immigrants into categories based on their arrival before or after the law’s enactment on August 22, 1996. With few exceptions⁸, both pre-enactment and post-enactment qualified immigrants became ineligible for SSI and food stamps. States are now given the option of providing federally-funded Medicaid and TANF and are required to provide SCHIP to pre-enactment qualified immigrants. States are prohibited from providing federally-funded means-tested benefits to post-enactment qualified immigrants for their first five years of lawful residency. States may deny or provide state-funded programs to both pre-enactment and post-enactment immigrants (including those denied federal benefits due to the five-year ban), though they may not place greater eligibility restrictions on state-funded programs than on federally-funded programs and must pass laws affirming their intent to provide these benefits. Additionally, the practice of ‘deeming’ a sponsor’s income as available to the immigrant now applies to Medicaid as well as TANF, SSI, and food stamps, until an immigrant become a citizen or has worked 40 quarters.

The 1997 Balanced Budget Act restored SSI benefits to those immigrants who were recipients as of August 22, 1996 or those who were residing in the country as of that date and had since become disabled. SSI benefits are still denied to immigrants entering the US after August 22, 1996 and those who were younger than 65 as of August 22, 1996.

In 1998⁹, food stamp eligibility was restored for immigrants with disabilities, immigrant children under 18 years of age, and immigrants who were at least 65 on August 22, 1996. In 2002¹⁰, eligibility was further restored for all persons who have lived in the US as qualified immigrants for at least five years, all immigrant children, and immigrants receiving disability-related assistance.

Figure 1. Current Eligibility for Federal Medicaid and SCHIP

Medicaid

SCHIP

Citizens
LPRs who arrived before August 22, 1996 (at state option—currently only Wyoming denies Medicaid to these LPRs)
LPRs who arrived after August 22, 1996 with five years of residence (deeming applies until citizenship or 40 work quarters is achieved)
Refugees and asylees, for first seven years
Victims of trafficking
Veterans or military personnel and their spouses and dependents
Victims of domestic abuse (with substantial connection between the abuse and the needed benefit)
Immigrant children receiving federally funded foster care
SSI recipients

Citizens
LPRs who arrived before August 22, 1996
LPRs who arrived after August 22, 1996 with five years of residence (deeming applies until citizenship or 40 work quarters is achieved)
Refugees and asylees
Victims of trafficking
Veterans or military personnel and their spouses and dependents
Victims of domestic abuse (with substantial connection between the abuse and the needed benefit)

References

American Immigration Lawyers Association (1997). Questions and Answers on Welfare Reform. Washington, DC: Author. Retrieved from
http://www.aila.org/Content/default.aspx?docid=14749.

Kaiser Foundation (2006). New Requirements for Citizenship Documentation in Medicaid. Washington, DC: Author. Retrieved from http://www.kff.org/medicaid/7533.cfm.

Morse, Ann (1998). America’s Newcomers: Mending the Safety Net for Immigrants. Washington, DC: National Conference of State Legislatures.

National Immigration Law Foundation (2006). Guide to Immigrant Eligibility for Federal Programs Update. Retrieved from http://www.nilc.org/pubs/Guide_update.htm.

National Immigration Law Center (2002) Guide to Immigrant Eligibility for Federal Programs: 4^th Edition. Los Angeles, CA: Author.

National Immigration Law Center (1994) Guide to Alien Eligibility for Federal Programs: 3^rd Edition. Los Angeles, CA: Author.

Singer, Audrey (2004). Welfare Reform and Immigrants. Washington, DC: The Brookings Institution. Retrieved from
http://www.brookings.edu/metro/publications/200405_singer.htm.

Notes

National Immigration Law Foundation (2006). Guide to Immigrant Eligibility for Federal Programs Update. Retrieved from http://www.nilc.org/pubs/Guide_update.htm.
Passed on February 8, 2006, and effective July 1, 2006.
There is also some concern that these provisions of the DRA will have a negative effect on citizens, instead of simply deterring ineligible immigrants. Of special concern are the elderly (who may have been born at home and therefore lack a birth certificate), victims of natural disaster or house fires (who may have lost all documentation), and the poor (who may not be able to afford the cost of replacing or acquiring documents).
Medicaid, Assistance to Families with Dependent Children (AFDC), Supplementary Security Insurance (SSI), food stamps, etc.
“Permanently residing in the US under color of law”—includes persons fleeing persecution, aliens paroled into the US, lawful temporary residents under the amnesty programs, aliens granted permission to remain in the US (i.e. stay of deportation), aliens who resided in the US since before January 1, 1972, and aliens residing in the US with INS knowledge and permission.
Medicaid, SSI, TANF (Temporary Assistance to Needy Families, the successor of AFDC), food stamps, and SCHIP (State Children’s Health Insurance Program) after it’s creation in 1997.
A substantial connection must be shown between the abuse and the needed benefit, and the immigrant must no longer reside with the abuser.
Three groups were exempted from this bar: certain aliens admitted for humanitarian reasons (refugees), veterans or current members of the Armed Forces and their spouses and dependent children, and LPRs who have worked 40 qualifying quarters.
Under the Agriculture Research, Extension, and Education Reform Act of 1998.
Under the Farm Security and Rural Investment Act (Farm Bill) of 2002.

Prepared by Laura Dwyer and Shirley Min, Research Fellows
NCSL’s Immigrant Policy Project and
Forum for Health Policy and Leadership

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