IMMIGRANTS AND HEALTH CARE
IN CALIFORNIA:
ELIGIBILITY
ENROLLMENT CHALLENGES
COSTS OF BEING UNINSURED
Gabrielle Lessard
National Immigration Law Center
Who We Are
National Immigration Law Center (NILC)


Our mission is to defend & advance the rights &
opportunities of low-income immigrants and their
family members.
We provide publications, offer technical assistance
and training, and engage in advocacy and strategic
litigation.
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Eligibility
Major Health Coverage Options

Covered California
 state

health insurance marketplace/exchange
Medi-Cal
 Full-scope
 Limited-scope
 Emergency,

pregnancy, etc.
Services open to all
 Includes emergency Medi-Cal, community
health centers, some county programs
Eligibility for Medi-Cal
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Full scope:
 Qualified
immigrants
 PRUCOLs
 Lawfully
present children
Limited scope (most often emergency or
pregnancy):
 Others
 All
must meet income and residency
requirements
Qualified Immigrants
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





Lawful permanent residents, or LPRs (persons with green
cards).
Refugees, persons granted asylum or withholding of
deportation/removal, and conditional entrants.
Persons granted parole by the Department of Homeland
Security (DHS) for a period of at least one year.
Cuban and Haitian entrants.
Certain battered immigrants, their children, and/or their
parents.
Certain victims of trafficking.
For the complete list see Overview of Immigrant Eligibility for Federal Programs at:
http://www.nilc.org/table_ovrw_fedprogs.html
PRUCOL
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Permanently Residing Under Color of Law - not an immigration
status, but a benefit eligibility category (see MC 13 Form – Statement
of Citizenship, Alienage, and Immigration Status). May include persons:

with approved immediate relative visa petition

who filed application for adjustment to LPR status

granted deferred action (including DACA)

granted Family Unity status

granted a stay of deportation

who have lived in the US continuously since before Jan. 1, 1972

who are survivors of domestic violence (certain immigrants)

Other persons in the US with the knowledge of DHS whose
departure that agency does not contemplate enforcing.
State Residency
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

Live in CA with intent to reside here, or
Live in CA and entered State with job commitment or
to seek employment, whether or not currently
employed.
Children generally assume the residence of their
parents, with an opportunity to establish state
residence independently.
Eligibility for Covered California
Lawfully Present
Qualified
lawfully present
immigrants are eligible to
purchase health coverage
through state health care
marketplaces
exception:
People who received
deferred action through
DACA are specifically
excluded
Lawfully Present Noncitizens
• All “qualified” immigrants
• Others authorized to live and/or work in the U.S., e.g.
• temporary protected status (TPS)
• most with deferred action
• Applicants for: adjustment to LPR and certain other statuses
• Asylum applicants with employment authorization
• Family immigrants with available visa
•
Individuals with valid nonimmigrant status
• Students, workers, etc.
• May not satisfy the residency requirement
Complete list:
https://www.healthcare.gov/immigration-status-and-the-marketplace/
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Enrollment Challenges
Barriers
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



Confusion about eligibility
Problems in application process
Language access issues
Lack of information/misinformation
 Concern
that receiving benefits or having medical debt
will interfere with ability to naturalize or adjust status
(“public charge”)
 Fears about jeopardizing family members
 Belief that benefits will need to be repaid by recipient
or sponsor
Public Charge
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“Public charge”: likely to become primarily dependent on government for
subsistence, as demonstrated by:

receipt of public cash assistance for income maintenance or

institutionalization for long-term care at government expense
“Totality of circumstances”: age, health/disability, income, education,
job/skills, family situation and affidavit of support
Can result in denial of:

Admission to U.S., or adjustment to Lawful permanent resident status

But not relevant for citizenship applicants, asylees, survivors of
domestic violence, trafficking, serious crime, etc.
Not relevant in public charge determinations:

Medical benefits other than long-term care

Non-cash benefits (e.g., SNAP, WIC)

“earned benefits” or cash for food, housing, child care, etc.
Immigration Enforcement
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Information provided on applications is confidential

Information about immigration status may be used only to determine an applicant’s
eligibility for health care coverage.
U.S. Immigration and Customs Enforcement (ICE) has released a notice stating that
information provided in health insurance application process will not be used for civil
immigration enforcement

On October 25, 2013, U.S. Immigration and Customs Enforcement (ICE)
issued a memo titled “Clarification of Existing Practices Related to Certain
Health Care Information,” confirming that immigrant parents can enroll their U.S.
citizen children and other eligible family members in health insurance programs
under the ACA without triggering immigration enforcement activity.
http://www.ice.gov/doclib/ero-outreach/pdf/ice-aca-memo.pdf
http://www.ice.gov/espanol/factsheets/aca-memoSP.htm
Information Provided to Covered CA
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
People submitting application must provide basic information about
all members of the tax household.

Subsidies are based on tax household income

Only individuals who are applying for coverage are required to
provide their immigration/citizenship status.

The Social Security Number (SSN) of a non-applicant may be
requested to electronically verify household income.

A non-applicant can be required to provide an SSN only if that
person is:



a primary tax filer,
who has an SSN, and
is applying for tax credits.
Key Issues for Mixed-Status Families
•
Undocumented people may apply for coverage on behalf of
their dependent family members




Applications should distinguish between applicants (e.g., U.S.
citizen child) & non-applicants (e.g., undocumented parent)
Non-applicants are not required to provide their immigration
status
Non-applicants without SSNs cannot be required to provide one
 Never provide an SSN unless officially issued by the Social
Security Administration
 Individual Taxpayer Identification Numbers (ITINs) should not
be used
Information provided on an application may be used ONLY to
determine eligibility for health insurance. 16
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Costs of Being Uninsured
Individuals
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
Uninsured people live sicker and die younger
 Diagnosed
in later stages of disease
 cancer
 More
likely to die from accidents and acute conditions
 Heart
 Less
likely to know they have asymptomatic conditions
 HIV,


attack, stroke
diabetes, high blood pressure
More likely to have medical debt
More likely to miss work or retire early due to
illness
Health Care System
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
Hospitals tend to terminate less profitable services
 These
are generally services used by the uninsured
 Emergency,

maternity, psychiatric
Health and hospital systems invest in areas with
more insured residents
 Doctors
generally prefer newer facilities and
equipment
 Hospitals with older facilities have more difficulty
recruiting on-call specialists, resulting in longer wait
times for everyone
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National Immigration Law Center:
Www.Nilc.Org
lessard@nilc.org