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The Immigrant Policy Project

Medical Assistance & Health Benefits
11/29/97

The 1996 federal welfare reform law made significant changes to immigrants' eligibility for medical assistance, allowing states to deny Medicaid benefits to current immigrant residents and effectively denying access to Medicaid for new arrivals until the immigrant works 40 quarters or becomes a citizen. In the 1997 state legislative sessions, most states decided to continue Medicaid for current residents and bar Medicaid for new arrivals. Several states authorized some state funds for those barred from federal benefits, such as children and elderly, and a few states sought to implement new deeming provisions and state residency requirements.

Background

Medicaid is an entitlement program jointly funded by federal and state governments to provide medical care for low-income pregnant women and children and individuals who are aged, blind, or disabled. In general, those eligible for Aid to Families with Dependent Children, now Temporary Assistance to Needy Families (TANF), and Supplemental Security Income (SSI) were automatically eligible for Medicaid. States must cover these mandatory groups. States have an option to cover other needy groups, such as those with higher family incomes or the "medically needy" who meet the non-financial standards for coverage but exceed the income and resource requirements. Income levels are generally based on the federal poverty level, which is currently $16,000 for a family of four. In addition to being low-income, applicants must be at least one of the following: blind (20/200 with corrective lenses), elderly (65 years or older), disabled (physically or mentally unable to obtain "substantial gainful employment" for 12 continuous months), children (maximum age of 18-21, depending on the state), or pregnant.

Immigrants have been eligible for Medicaid benefits largely on the same basis as citizens. The following categories of immigrants were previously eligible to receive Medicaid: lawful permanent residents; refugees, asylees, those granted withholding of deportation, parolees, Cuban and Haitian entrants, conditional entrants; aliens granted indefinite voluntary departure, stay of deportation, suspension of deportation, and order of supervision; residents since 1972; and those permanently residing under color of law (PRUCOL). Immigrants granted temporary protected status, family unity, non immigrants, and unauthorized immigrants were eligible only for emergency medical assistance.

The Federal Welfare Law of 1996

The Personal Responsibility and Work Opportunity Act of 1996 established, for the first time, a bar on immigrants' access to Medicaid. Federal savings from the Medicaid provisions were estimated at $5 billion over 7 years, affecting approximately 600,000 immigrants. The law cut $23.8 billion in benefits for legal immigrants, accounting for 44% of the federal savings in the welfare law. Most of the savings derived from barring most non citizens from the Supplemental Security Income Program (SSI). The loss of SSI also threatened the automatic link to Medicaid eligibility for many elderly and disabled immigrants.

Significant Medicaid provisions in the welfare law include:

• TANF eligibility no longer automatically provides eligibility for Medicaid; however, those who would have been eligible for Medicaid under AFDC as of July 16, 1996 may retain Medicaid eligibility.
• Immigrants arriving after the law's enactment on August 22, 1996 are barred from Medicaid for five years, with exceptions for refugees and veterans.
• After the five-year bar, these immigrants are subject to "deeming": the income and resources of the sponsor and the sponsor's spouse are deemed, or counted, as available to the immigrant in determining his or her eligibility for Medicaid. Deeming applies until the immigrant works 40 quarters or becomes a citizen. Refugees and other humanitarian entrants are not sponsored and therefore are not subject to deeming.
• States have the option to provide or deny Medicaid to immigrants residing in the U.S. on or before enactment. States will receive federal matching funds for these immigrants. It is unclear whether states may waive the deeming requirements after the five-year bar for new arrivals.
• States may provide or deny state-funded programs to current residents or newly-arriving immigrants, nonimmigrants (e.g., tourists), and those paroled into the U.S. for less than one year. States must provide benefits to refugees, asylees, withholding of deportation, Cuban and Haitian Entrants, and Amerasians for their first five years in the U.S.; veterans and active duty military, spouses, and dependents; and immigrants with 40 work quarters. States may deem when the new affidavits of support become effective, December 19, 1997. Exempted programs include: emergency medical, emergency disaster, school and child nutrition programs, public health assistance for immunizations and testing/treatment of symptoms of communicable disease; and payments for foster care/adoption assistance/A.G. discretion programs.
• States may not provide Medicaid to "not qualified" aliens. "Not qualified" includes undocumented immigrants, nonimmigrants, and PRUCOLs.
• States that wish to provide medical assistance to "not qualified" aliens, other than emergency medical, must pass a law affirmatively providing such services after the federal welfare law's enactment, even if the state already had such a law in place.
• States may not use Medicaid funds for public health immunizations or for testing and treatment of symptoms of communicable diseases for qualified immigrants arriving after 8/22/96 or for "not qualified" aliens.
• Emergency medical assistance must be provided to all immigrants, regardless of status. Emergency services include medical conditions, including labor and delivery, with acute symptoms that could place the patient's life in jeopardy, impair bodily functions, or cause serious dysfunction of any bodily organ or part. All labor and delivery services fall within the definition of emergency medical services.
• The INS must issue regulations by February 1998 regarding verification that immigrant applicants for "public benefits" (as yet undefined) are qualified aliens and eligible for such benefit. States must comply within 2 years. The INS issued interim guidance on verification on November 17, 1997.

The Balanced Budget Law of 1996
The Balanced Budget Act of 1997 (BBA), P.L. 105-33, reversed $11.4 billion of immigrant benefits stripped away by the 1996 welfare reform law. The act restored SSI to individuals who were receiving SSI benefits on August 22, 1996. Immigrants lawfully residing in the U.S. as of that date who are or become disabled will be eligible for Medicaid and SSI benefits. Current recipients who are PRUCOL may retain their SSI and Medicaid benefits until September 30, 1998. This helps approximately 24,000 recipients who are not considered "qualified aliens," who would otherwise lose benefits this year. The law specifically retains "derivative eligibility," that is, immigrants receiving SSI may retain eligibility for Medicaid. Those who remain barred from SSI are low-income immigrants residing in the U.S. as of enactment who become elderly (turn 65) but are not disabled.

The Act lengthens from five to seven years the period during which Medicaid eligibility is guaranteed to refugees, asylees, and aliens whose deportation has been withheld. Cuban and Haitian Entrants and Amerasians (children born in Southeast Asia of U.S. military or civilian personnel during the Vietnam War) have been added to this seven year extension. Certain American Indians living along the Canadian border who have legal permanent resident status are exempted from the SSI and Medicaid bar.

The BBA also restored SSI and Medicaid to recipients who applied for benefits prior to 1979, the year that the Social Security Administration began asking for proof of citizenship or immigration status. This provision affected many citizens as well as immigrants who were at risk of losing benefits because they had no birth certificates or other documentation proving citizenship or naturalization.

Additional funding will be provided to states with high numbers of undocumented aliens for emergency health services. For each of the four fiscal years (1998-2001), $25 million will be distributed among the twelve states with the highest number of undocumented aliens. The 1992 estimates prepared by the Statistics Division of the INS will be used to determine which states will receive the funds. The twelve states with the greatest number of undocumented aliens in 1992 were: Arizona, California, Colorado, Florida, Illinois, Maryland, Massachusetts, New Jersey, New York, Texas, Virginia, and Washington.

Battered spouses and children. The immigration reform law of 1996 amended the definition of qualified alien to include battered women/spouses and children. The law would have required the Attorney General to determine on a case by case basis the existence of a "substantial connection" between the battery and the need for benefits. The balanced budget law allows the benefit agency to determine the substantial connection between battery and benefit according to guidance issued by the Attorney General.

Amended Definitions

The law contains a "sense of Congress" provision that Hmong and other highland Lao lawful permanent residents who fought on behalf of the U.S. during the Vietnam conflict should be considered veterans. However, this language does not carry the force of law. Congress must pass specific language to extend veteran status to this population.

The definition of "veterans" has been clarified to include all veterans, such as Filipinos eligible for veteran benefits, and clarifies spouse to include widows and widowers.

Medicare

Medicare provides hospital and supplemental medical insurance for those over 65 and disabled. Most Americans aged 65 and over are automatically eligible for Medicare through the payroll tax on earnings covered by Social Security. The welfare law permitted those who paid into Social Security to receive that benefit, but not Medicare. The balanced budget act permits immigrants to receive Medicare if the immigrant was lawfully present when the work was performed and is lawfully present when benefits are provided.

State Action

The recent changes in federal legislation to continue immigrant eligibility and lengthen the period of coverage for various classes of immigrants came after nearly all states had ended their legislative sessions. Therefore, the majority of the state legislation passed concerning immigrants' receipt of Medicaid were based on immigrant eligibility guidelines set forth in the Personal Responsibility and Work Opportunity Reconciliation Act of 1996.

The Health Care Financing Administration (HCFA) of HHS has informed states that if they intend to deny Medicaid to qualified aliens who were in the U.S. prior to August 22, 1996, they must file a state plan amendment. According to HCFA, Wyoming, West Virginia, and Louisiana filed such amendments. West Virginia and Louisiana have since reversed their decisions to deny Medicaid.

Most states seem to be simply codifying the federal law, providing Medicaid to current residents, denying Medicaid to new arrivals, and authorizing emergency assistance to "not qualified" aliens. A few states have funded medical assistance for prenatal care, for children, or for nursing home residents. A few states, Arizona, New York, Minnesota, and Nebraska intend to begin deeming.

Medical Assistance for Post-Enactment Immigrants

• Connecticut will provide state funded medical assistance until July 1, 1999 for individuals who arrived after the August 22, 1996 cutoff date and were determined eligible for Medicaid prior to July 1, 1997. Those not determined eligible before July 1, 1997 may receive assistance after six months' residency in Connecticut, until July 1, 1999. Victims of domestic violence and those with mental retardation may receive benefits.
• Rhode Island will continue to provide Medicaid benefits to non-citizen children that were legally admitted for permanent residence on or after August 22, 1996.
• Nebraska allows qualified immigrants to receive medical assistance, regardless of their date of entry, though deeming applies. This decision will require the state to pay the full cost of the Medicaid for those individuals that arrived after August 22, 1996. Nebraska estimates this will cost the general fund $200,000 during FY1998 and $275,000 during FY1999.
• Washington law will continue Medicaid to post-enactment immigrants if the parents or legal guardians have resided in the state for at least twelve months.
• Louisiana enacted an appropriations bill funding programs that may serve immigrant and refugee communities, but does not address eligibility standards. Services provided include: preventive services to promote reduced morbidity and mortality resulting from chronic diseases, infectious/communicable diseases, high risk conditions of infancy and childhood and accidental and intentional injuries. Specific activities include immunizations, influenza high-risk services, refugee health screening, tuberculosis control, family planning and maternal and child health.
• Massachusetts enacted a law giving MassHealth medical benefits to persons who would not qualify for Medicaid under the Welfare Reform Act.
• Minnesota has enacted legislation barring undocumented and nonimmigrants from medical care other than emergency services, but exempts children, Cuban and Haitian Entrants, and aliens who are aged, blind, or disabled. Medicaid will be available to legal post-enactment immigrants who have sponsors and affidavits of support.
• Arizona passed legislation that non citizens who do not provide verification of qualified alien status shall only be eligible for emergency medical services. Deeming shall apply to eligibility determinations for all qualified aliens. For the purposes of hospitalization and medical care, the state's definition of indigent is expanded to include qualified aliens who entered the country pre enactment or post enactment and are members of the excepted groups identified in the federal welfare reform law.
• New York will provide safety net and medical services necessary for treatment of an emergency medical condition for newly arriving immigrants and PRUCOLs. Medical Assistance benefits are limited to care and services (not including organ transplant procedures) necessary for the treatment of an emergency medical condition. This coverage may increase with available federal financial participation. After the five-year ban on Medicaid, the income of the immigrant's sponsor will be "deemed". New immigrants are eligible only for Emergency Medicaid, unless the state changes its policy, or federal financial participation become available.

• Virginia will provide full medical assistance services to noncitizens under age 19 who would be eligible for Medicaid but for the federal welfare law.
• Maryland will provide medical care and other health services for legal immigrant children and pregnant women arriving after August 22, 1996.
• In California, the legislature authorized continuance of prenatal care for unauthorized immigrants, but the Governor vetoed the language. Proposed regulations would end the program in January, 1998 for new applicants and in February for existing recipients.
• Illinois' governor signed a law stating that the Illinois Department may, by rule, cover prenatal care or emergency medical care for non-citizens who are not otherwise eligible.
• Rhode Island plans to provide Medicaid coverage for children and noncitizen women and prenatal, delivery, and postpartum care for any women who lacks health insurance and cannot qualify for medical assistance under Medicaid, regardless of their date of entry in the U.S.

• Virginia will continue to serve immigrants receiving Medicaid and residing in long-term care facilities or participating in home-and community-based waiver programs on June 30, 1997, at state expense if federal financial participation is not available.
• New York will continue medical assistance for PRUCOL immigrants who were receiving assistance as of 8/4/97 and living in a residential health care facility.
• A Connecticut law provides home-care services for qualified aliens.

• Guide to Alien Eligibility for Federal Programs, National Immigration Law Center, (Los Angeles, CA, 1994.
• "Welfare Reform & Immigrants: State Trends," Immigrant Policy Project, NCSL
• "Welfare Reform & Immigrants: Medicaid Provisions Q&A," Lynda Flowers, NCSL (Washington, D.C., 4/10/97)
• Immigrant Policy News ... State LegisLine, Immigrant Policy Project, NCSL (Washington, D.C.)

Contacts

National Immigration Law Center
1815 H Street, N.W.
Suite 501
Washington, D.C. 20006
tel: 202-776-0470
fax: 202-776-0474

Health Care Financing Administration
Division of Intergovernmental Affairs

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, D.C.
tel: 202-690-8501
www.acf.dhhs.gov/news/welfare/wrpack.htm

"Welfare Reform and Immigrants" is published by the Immigrant Policy Project of the State and Local Coalition on Immigration. Members of the State and Local Coalition are: the National Governors' Association, the National Conference of State Legislatures, the United States Conference of Mayors, the National League of Cities, the National Association of Counties, and the American Public Welfare Association. The Project is funded by the Andrew W. Mellon Foundation. This issue brief series is supported by the Ford Foundation. The Project is located in the Washington, D.C. office of the National Conference of State Legislatures.

Staff
Editor: Ann Morse
Contributors: Shawn Porter Heusser
Molly J. Surden
Jeremy D. Meadows
444 North Capitol Street, N.W., Suite 515
Washington, D.C. 20001
tel: 202-624-5400 fax: 202-737-1069

No parts of this publication may be reproduced, reprinted or republished without the Health Policy Tracking Services' written permission and appropriate attribution.