Medicaid, established in 1965, is a federal- and state-funded insurance program offered to low-income individuals. Prior to the establishment of the ACA, to qualify for Medicaid an individual had to meet financial criteria and fall into a category that is eligible for the program, including children, parents of dependent children, pregnant women, people with disabilities and the elderly. Federal law set the minimum requirements for eligibility and benefits. However, states had the authority to extend Medicaid beyond these minimum standards using their own funds, leading to variations in Medicaid coverage throughout the states. The ACA allowed states to use federal money to cover all individuals up to 138 percent of the FPL, regardless of whether they fit into one of the categories.
The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 added restrictions on legal immigrants’ eligibility for Medicaid. Prior to this law, most immigrants were eligible for public benefits, including health care, on much the same basis as citizens. PRWORA created the qualified immigrant standard and the five-year bar, when applicable, for immigrants who enter the United States on or after Aug. 22, 1996. Certain groups are exempt from the five-year bar, such as refugees and veterans. States can choose whether to provide or limit public benefits to immigrants.
Since 1996, non-emergency Medicaid has been generally limited to citizens and “qualified immigrants.” This limited eligibility standard includes people who are lawful permanent residents, also known as green card holders, and humanitarian forms of relief, such as asylum-seekers and refugees, victims of domestic violence, and trafficking victims. Qualified immigrants are subject to a five-year waiting period before obtaining Medicaid coverage, unless they hold a status that is exempt from the waiting period, which is generally the humanitarian forms of relief. Since 2009, states can also elect to use federal matching funds to cover all lawfully present children and pregnant women without a waiting period.
Children’s Health Insurance Program (CHIP)
The Children’s Health Insurance Program (CHIP), established in 1997, offers low-cost health coverage for children in families whose household income is higher than the standard to qualify for Medicaid. CHIP provided health insurance coverage to low-income children under age 19 based on their household income, at household levels set by the state. States could choose to administer CHIP as an expansion of the state Medicaid program, as a standalone insurance program or as a combination of these approaches. Eighteen states operated separate CHIP programs, 11 states and the District of Columbia implemented CHIP by expanding Medicaid and 21 states used a combination approach. States that implemented CHIP through Medicaid expansions received federal funding at the lower Medicaid matching rate if they exceeded their federal CHIP allotment.
Immigration-related eligibility for CHIP mirrors that of Medicaid, meaning that generally it covers qualified immigrants, with the five-year bar when applicable, but states can elect to cover all lawfully present children and pregnant women.
The Affordable Care Act (ACA)
The Affordable Care Act (ACA), enacted in 2010, aimed to expand affordable coverage for many Americans through access to insurance, consumer protections, prevention and wellness, quality, an expanded health workforce, and curbing the rise of health care costs. The ACA is actually a combination of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010; which together, were able to extend Medicaid coverage to adults whose income was below 138 percent of the Federal Poverty Line ($16,643 for individuals) for states that chose to expand.
The ACA created new marketplaces for health care insurance and allowed states to expand Medicaid to cover new populations; covered those with preexisting conditions; extended coverage for children up to age 26, removed the waiting period for enrolling in state insurance exchanges, and extended eligibility for basic health plans, premium tax credits, and lower copays.
The ACA also expanded which categories of immigrants were eligible for comprehensive health insurance programs by using the standard of “lawfully present” for eligibility, which is broader than the qualified immigrant standard for Medicaid established as part of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996. The term lawfully present includes “qualified” immigrants, humanitarian entrants, victims of trafficking, and certain immigrants with permission to live and work in the U.S. Deferred Action for Child Arrivals are not considered lawfully present for marketplace coverage.
Under the ACA, lawfully present immigrants are eligible to enroll in health insurance plans from either the federal or state insurance exchanges. This eligibility standard is used throughout the ACA-created structures, including premium tax credits, cost sharing reductions, and Basic Health plans, although it did not change the eligibility for Medicaid for states that expanded their program. The chart below lists the services that are offered to lawfully present immigrants under the ACA. The law did not make substantive changes in health access for people who are not lawfully present.