Understanding The Individual Mandate For Lawfully Present Immigrants

Lawfully present immigrants in the United States are eligible for affordable coverage options under the Affordable Care Act (ACA) of 2010. Lawfully present immigrants can get Marketplace coverage and may qualify for premium tax credits and other savings on Marketplace plans. They may also be eligible for Medicaid and the Children's Health Insurance Program (CHIP). However, there is usually a five-year waiting period for full Medicaid or CHIP coverage after being granted immigration status. States have the option to waive this waiting period and provide coverage for lawfully residing children and/or pregnant women.

Lawfully present immigrants and Marketplace savings

As of November 1, 2024, Deferred Action for Childhood Arrivals (DACA) recipients are eligible for Marketplace coverage. Lawfully present immigrants can get Marketplace coverage and may qualify for premium tax credits and other savings on Marketplace plans.

The term "lawfully present" includes immigrants with "Qualified Non-Citizen" immigration status, humanitarian statuses, valid non-immigrant visas, and legal status conferred by other laws. Lawfully present immigrants can benefit from Marketplace savings by purchasing private health insurance on the Marketplace. They may be eligible for lower monthly premiums and reduced out-of-pocket costs based on their income.

The Federal Poverty Level (FPL), issued by the Department of Health and Human Services (HHS), determines eligibility for savings. If an immigrant's annual income is above 400% FPL, they may still qualify for premium tax credits to lower their monthly premium. With an annual income between 100% and 400% FPL, they may qualify for additional savings on Marketplace health coverage. Those with an annual income at or below 150% FPL who are not eligible for Medicaid or the Children's Health Insurance Program (CHIP) may enroll in Marketplace coverage through a Special Enrollment Period.

Furthermore, "qualified non-citizens" are generally eligible for coverage through Medicaid and CHIP if they meet state income and residency rules. While many qualified non-citizens have a 5-year waiting period for Medicaid and CHIP coverage, exceptions are made for refugees, asylees, and LPRs who previously held these statuses.

Medicaid and CHIP coverage

Lawfully present immigrants in the US may qualify for Medicaid and CHIP, but they are subject to eligibility restrictions. In general, lawfully present immigrants must have a "qualified" immigration status to be eligible for these programs. Many, including most lawful permanent residents or "green card" holders, must wait five years after obtaining qualified status before they may enrol, even if they meet other eligibility requirements.

Some immigrants with qualified status, such as refugees and asylees, as well as citizens of Compact of Free Association (COFA) communities, do not have to wait five years before enrolling. However, some immigrants, such as those with Temporary Protected Status, are lawfully present but do not have a qualified status and are therefore ineligible to enrol in Medicaid or CHIP regardless of their length of time in the country.

For children and pregnant people, states can eliminate the five-year wait and extend coverage to lawfully present immigrants without a qualified status. As of March 2024, 37 states plus the District of Columbia have taken up this option for children, and 30 states plus the District of Columbia have elected the option for pregnant individuals.

In addition, 22 states have also extended coverage to pregnant people regardless of immigration status through the CHIP From-Conception-to-End-of-Pregnancy (FCEP) option. While other pregnancy-related coverage in Medicaid and CHIP requires 60 days of postpartum coverage, the CHIP FCEP option does not include this. However, some states that adopted this option provide postpartum coverage regardless of immigration status through a CHIP state plan amendment or using state-only funding.

Furthermore, lawfully present immigrants can purchase coverage through the Affordable Care Act (ACA) Marketplaces and may receive tax credits for this coverage without a waiting period. As of November 1, 2024, Deferred Action for Childhood Arrivals (DACA) recipients may be eligible for Marketplace coverage and tax credits.

Undocumented immigrants are ineligible to enrol in Medicaid or CHIP or to purchase coverage through the ACA Marketplaces. However, Medicaid payments for emergency services may be made on behalf of individuals who are otherwise eligible for Medicaid but for their immigration status. These payments cover the costs of emergency care for lawfully present immigrants who remain ineligible for Medicaid, as well as for undocumented immigrants.

Emergency care

As of November 1, 2024, Deferred Action for Childhood Arrivals (DACA) recipients may be eligible for Marketplace coverage. Lawfully present immigrants can get Marketplace coverage and may qualify for premium tax credits and other savings on Marketplace plans.

Medicaid provides payment for the treatment of emergency medical conditions for people who meet all the eligibility criteria in the state, such as income and state residency, but who do not have an eligible immigration status. This includes lawfully present immigrants who remain ineligible for Medicaid, as well as undocumented immigrants.

The Emergency Medical Treatment & Labor Act (EMTALA), a federal law, requires Medicare-participating hospitals to provide screening and stabilization services for anyone who enters their emergency rooms, without regard for insurance or residency status.

Since emergency rooms are usually the most expensive setting for healthcare, local officials in many areas have opted for less expensive alternatives. Of the 25 US counties with the largest number of undocumented immigrants, 20 have programs in place to fund primary and surgical care for low-income uninsured county residents, typically regardless of their immigration status.

Public charge status

The term "public charge" refers to a person who is dependent on the government for survival. This status is a ground of inadmissibility, meaning that it can be a reason for a person to be denied a green card, visa, or admission into the United States. When deciding whether to grant a green card or visa, an immigration officer must assess whether an applicant is likely to become a public charge in the future. This means that they will evaluate whether the individual is likely to rely heavily on certain government benefits.

It is important to note that the public charge test does not apply to everyone, even among those applying for green cards. Furthermore, applying for or receiving Medicaid or CHIP benefits, or savings for Marketplace health coverage, does not make one a public charge. This means that it will not affect an individual's chances of becoming a Lawful Permanent Resident or U.S. citizen. The only exception is for people receiving long-term care in an institution at government expense, such as in a nursing facility, who may face barriers in obtaining a green card.

The Biden Administration's public charge regulations, which went into effect on December 23, 2022, provide clarifications on issues such as immigrant exemptions and the circumstances under which receiving public benefits will or will not impact an individual's public charge status. These regulations mirror the policies set forth in the 1999 Field Guidance on public charge. The Department of State (DOS) has also finalized similar regulations for applications processed abroad.

Lawfully present immigrant categories

The term "lawfully present" applies to several categories of immigrants in the United States. These categories include:

Qualified Non-Citizen

Qualified non-citizens are immigrants with permanent resident status (LPR/Green Card Holders). This category also includes Cuban/Haitian entrants, individuals paroled into the U.S. for at least one year, conditional entrants granted before 1980, battered non-citizens, and their spouses, children, or parents. Additionally, it covers victims of trafficking and their immediate family members or those with pending applications for a victim of trafficking visa. Those granted withholding of deportation and members of a federally recognized Indian tribe or American Indians born in Canada are also considered qualified non-citizens. Finally, citizens of the Marshall Islands, Micronesia, and Palau residing in U.S. states or territories (referred to as COFA migrants) fall under this category.

Humanitarian Statuses or Circumstances

This category includes individuals with Temporary Protected Status, Special Juvenile Status, asylum seekers, applicants under the Convention Against Torture, and victims of trafficking. These individuals may be eligible for humanitarian protection or asylum, depending on their specific circumstances.

Valid Non-Immigrant Visas

Individuals with valid non-immigrant visas are also considered lawfully present. This category includes individuals with visas that allow them to live and/or work in the U.S. temporarily without immigrating permanently.

Legal Status Conferred by Other Laws

Some immigrants may have legal status through other means, such as the LIFE Act, temporary resident status, or Family Unity provisions. These laws provide a pathway to legal presence in the U.S., even if the individual does not fall under the category of a qualified non-citizen.

It is important to note that the definition of "lawfully present" has been revised over time, with the most recent update in May 2024, which included Deferred Action for Childhood Arrivals (DACA) recipients as eligible for Marketplace coverage starting November 1, 2024.

Frequently asked questions