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Access to Public Health Insurance - Noncitizens, Legal Immigrants & Undocumented Residents

By Lorianne Maria Sainsbury-Wong posted Fri November 04,2016 01:22 PM


Where are we with respect to eligibility and access to public health insurance for all Massachusetts residents? The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) continues to dominate federal reimbursements to the Commonwealth regarding public health insurance programs. The PRWORA, for example, authorizes financial participation, e.g. federal funds, to Massachusetts on behalf of “qualified aliens”. It limits eligibility for public insurance to certain qualified immigrants who demonstrate five or more years of continual legal status and residency in the United States, which is also referred to as the five-year bar.  

Even after twenty years, the PRWORA extends its ambit over the Medicaid program, the pinnacle of our U.S. public healthcare system and a significant source of insurance coverage for Massachusetts residents under MassHealth. PRWORA prohibits "aliens who are not qualified aliens” from entitlement to coverage.  Exceptions exist, such as for those immigrants who seek access to emergency medical treatment.  In addition, on an annual basis those employers that offer employer sponsored insurance must notify employees that they may be eligible for premium assistance through Medicaid and the Children’s Health Insurance Program (CHIPRA). Here is a link to a model notice, issued by the U.S. Department of Labor, Employee Benefits Security Administration:  Moreover, CHIPRA offers assistance to noncitizens who are “lawfully residing” children or pregnant women in states that expanded Medicaid under CHIPRA.  This link discusses the dramatic reduction in U.S. children’s uninsurance rates as a result of CHIPRA implementation: (“More Than 3 Million Children Have Coverage Due to Drop in Uninsured Rate Since 2008”). 

In addition to the above exceptions to the PRWORA, the PRWORA exempts some qualified immigrants, such as individuals who have been Congressionally designated with special humanitarian entrance into the U.S., e.g. asylees and refugees.  Notably, in “Finch v. Commonwealth Health Ins. Connector Auth., 459 Mass. 611 (2011), the Massachusetts Supreme Judicial Court noted that "Congress [under the PRWORA] is indifferent to the use of State funds in providing public benefits to aliens qualified to reside in the [State] but ineligible for Federal benefits.”  States, such as Massachusetts, therefore, may allocate discretionary funding, as available to offer public healthcare programs for residents, without federal financial participation.

Depending on budget and related considerations, states may opt to implement insurance for residents in need, including immigrants who are undocumented. In Massachusetts, for instance, children and young adults -- ages 1-20 – may be eligible for MassHealth Limited, provided that their household income is at or below 150 150 % of the federal poverty level (FPL), e.g., $24,036 annually for a household of two.  In addition, undocumented children under age 19 receive the Children’s Medical Security Plan. And, pregnant women – regardless of immigration status or lack thereof – may qualify for MassHealth Standard, which is comprehensive coverage, so long as household income is at or below 200% FPL, e.g.  $32,040 for a family of two residents. 

Moreover, California, under Sen. Bill 10, 2015-2016 Reg. Sess. (Cal. 2016), has requested permission from the Centers for Medicare and Medicaid Services to grant a Section 1332 innovation waiver, pursuant to the Affordable Care Act, which would allow that state’s marketplace to sell nonsubsidized and qualified health insurance to undocumented immigrants.  These Californian residents would be obligated to pay all costs associated with the marketplace coverage. If allowed, the waiver could reduce the state's uninsurance rate by permitting undocumented Californians to pay full cost and enroll in marketplace insurance -- presumably at lower rates than the commercial market. 


Lorianne M. Sainsbury-Wong | Litigation Director & Compliance Atty. | healthlawadvocates | |

MBA Health Law Section Member, Chair (2014-2016), Co-Chair (2013) | MBA Civil Litigation Section Council Member (2016)

#IndividualRightsandResponsibilities #PublicLaw #ImmigrationLaw #HealthLaw