k ai
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commission
K
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on
medicaid
and the
uninsured
A C T S
April 2006
MEDICAID AND SCHIP ELIGIBILITY FOR IMMIGRANTS
Immigrants in the U.S. face increasing challenges securing
health care coverage. They have less access to employersponsored insurance than native citizens and face tighter
restrictions on their eligibility for Medicaid and SCHIP, the
nation’s major public health coverage programs for lowincome children and families. As a result, immigrants,
particularly non-citizens, are more likely to be uninsured than
native born citizens.
There were 35.2 million immigrants in the U.S. in 2004,
representing 12 percent of the total population. Nearly 40
percent were naturalized citizens, and just over 60 percent
were non-citizens. Of the total foreign-born population, an
estimated 30 percent were undocumented.i
Medicaid law establishes minimum eligibility levels for certain
populations, but also permits states to extend coverage
beyond the minimum levels. SCHIP covers children and a
very limited number of parents above the Medicaid eligibility
levels. Non-disabled childless adults are generally excluded
from Medicaid and SCHIP coverage (Figure 2).
Figure
Figure22
Minimum
Minimum Medicaid
Medicaid and
and SCHIP
SCHIP
Eligibility
Levels
Eligibility Levels
Income
Incomeeligibility
eligibilitylevels
levelsas
asaapercent
percentof
ofthe
theFederal
FederalPoverty
PovertyLevel:
Level:
Medicaid
Medicaid
100%
100%
IMMIGRANT HEALTH INSURANCE STATUS
133%
133%
Immigrants are more likely to be uninsured than native
citizens. Overall, they have lower rates of employersponsored insurance and are less likely to rely on publiclysponsored coverage programs. Although over 80 percent of
immigrant families have at least one full-time worker, they
are more likely to work in low-wage jobs and in industries
and firms that do not offer health insurance. Non-citizen
immigrants are less likely to have insurance and account for
21 percent of the nation’s nearly 46 million uninsured. The
disparities in insurance coverage are even more evident
when comparing low-income residents (Figure 1).
Figure
Figure11
Health
Health Insurance
Insurance Coverage
Coverage of
of the
the Low-Income
Low-Income
Nonelderly
Nonelderly by
by Citizenship
Citizenship Status,
Status, 2004
2004
100%
100%
28%
28%
75%
75%
50%
50%
25%
25%
6%
6%
28%
28%
0%
0%
39%
39%
59%
59%
38%
38%
Uninsured
Uninsured
Medicaid/Other
Medicaid/OtherPublic
Public
Private,
Private,Non-Group
Non-Group
Employer-Sponsored
Employer-Sponsored
23%
23%
8%
8%
19%
19%
3%
3%
31%
31%
19%
19%
Native
Native
Citizens
Citizens
Naturalized
Naturalized
Citizens
Citizens
Non-Citizens
Non-Citizens
74.7
74.7million
million
3.3
3.3million
million
11.7
11.7million
million
Medicaid/Other
Medicaid/OtherPublic
Publicalso
alsoincludes
includesSCHIP,
SCHIP,other
otherstate
stateprograms,
programs,Medicare,
Medicare,and
and
military-related
military-relatedcoverage.
coverage. Data
Datamay
maynot
not total
total100%
100%due
duetotorounding.
rounding.
Source:
Source:KCMU
KCMUanalysis
analysisofof2005
2005CPS
CPSdata
data
K A I S E R C O M M I S S I O N O N
K A I S E R C O M M I S S I O N O N
Medicaid
Medicaidand
andthe
theUninsured
Uninsured
Not having health insurance leads to disparities in access to
health care. Immigrants are less likely than citizens to have
a regular source of care, to visit a doctor in a given year, or
to obtain preventive care.ii Not having health insurance can
also place significant financial strain on low-income families.
MEDICAID AND SCHIP ELIGIBILITY RULES
To qualify for Medicaid and SCHIP, an individual must meet
both income and categorical eligibility requirements. Federal
1330 G STREET NW, WAS
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: 202-347-5274
H I N G T O N
A X
SCHIP
SCHIP
200%
200%
133%
133%
100%
100%
42%
42%
74%
74%
0%
0%
0%
0%
Pregnant
Pregnant Pre-School
Pre-School SchoolSchoolWomen
Children
Age
Women
Children
Age
Children
Children
Parents
Parents Elderly
Elderlyand
and Childless
Childless
Individuals
Individuals Adults
Adults
with
with
Disabilities
Disabilities
Note: The federal poverty level was $9,800 for a single person and $16,600 for a
Note: The federal poverty level was $9,800 for a single person and $16,600 for a
family of three in 2006.
family of three in 2006.
SOURCE: Cohen Ross and Cox, 2004 and KCMU, Medicaid Resource Book, 2002.
SOURCE: Cohen Ross and Cox, 2004 and KCMU, Medicaid Resource Book, 2002.
K A I S E R C O M M I S S I O N O N
K A I S E R C O M M I S S I O N O N
Medicaid
Medicaidand
andthe
theUninsured
Uninsured
MEDICAID AND SCHIP ELIGIBILITY RULES FOR IMMIGRANTS
The passage of the Personal Responsibility and Work
Opportunity Reconciliation Act (PRWORA) in 1996 changed
the eligibility requirements for immigrants, making it more
difficult for immigrants, especially those newly arrived in the
U.S., to obtain Medicaid coverage. For the first time, the
1996 law tied legal immigrants’ eligibility for Medicaid to their
length of residency in the U.S. These restrictions also
applied to SCHIP, which was established in 1997. The
following summarizes Medicaid and SCHIP eligibility rules
for immigrants today.
Most immigrants are subject to a five-year bar on
eligibility. Legal permanent residents (immigrants with
green cards) are ineligible for Medicaid or SCHIP during their
first five years in the U.S. After five years, they become
eligible for Medicaid and SCHIP if they meet the programs’
other eligibility requirements. Some immigrants are exempt
from the bar and are eligible for Medicaid and SCHIP
regardless of their length of residence. These include
refugees and most other humanitarian immigrants as well as
active-duty members or veterans of the U.S. Armed Forces
and their families. In 2004, 22 states and the District of
Columbia used state funds to provide coverage to some
immigrants ineligible for Medicaid and SCHIP.
Undocumented immigrants and immigrants in the U.S.
on a temporary basis (e.g., have temporary work visa or
student visa) are generally ineligible for Medicaid and
SCHIP. Regardless of their length of residence in the U.S.,
k ai
ser
commission
K
E Y
F
A C T S
undocumented and temporary immigrants are ineligible for
Medicaid and SCHIP. This restriction was in place prior to
PRWORA and remains in place today.
States can use SCHIP funds to provide prenatal care to
pregnant women, regardless of their immigration status.
In 2002, the Centers for Medicare and Medicaid Services,
which administers the SCHIP program, amended the SCHIP
regulations to provide states with the option of providing
SCHIP-funded prenatal care without applying an immigration
test. The rule extends SCHIP eligibility to a pregnant
woman’s fetus, which does not have an immigration status
and is not subject to the restrictions. Currently, seven states
provide SCHIP-funded prenatal care to pregnant immigrant
women.
Emergency treatment is available to all immigrants,
regardless of their status. Legal and undocumented
immigrants who meet all eligibility requirements except for
the immigrant eligibility restrictions are eligible for
Emergency Medicaid, which covers the costs of emergency
medical treatment. Additionally, the Emergency Medical
Treatment and Labor Act (EMTALA) requires hospitals to
screen and stabilize all individuals, including immigrants,
who seek care in an emergency room.
ADDITIONAL RESTRICTIONS ON MEDICAID AND SCHIP
ELIGIBILITY FOR LEGAL IMMIGRANTS
In addition to the eligibility restrictions described above,
federal law permits further limitations on Medicaid eligibility
for legal immigrants.
Sponsor deeming. Many legal immigrants, especially those
who come to the U.S. to be reunited with family members,
have sponsors who pledge to support them during their
transition to the U.S. Federal law requires that a portion of
the sponsor’s income and resources be included in
determining Medicaid eligibility for the immigrant regardless
of whether the sponsor shares any income with the
immigrant.iii In effect, sponsor deeming can push an
immigrant over a state’s income or asset limits for Medicaid,
even when they are very poor and have insufficient
resources to pay for care.
Additional state restrictions. Federal law permits states to
further restrict Medicaid and SCHIP eligibility to legal
permanent residents beyond the five-year bar (although they
are prohibited from applying these restrictions to refugees
and asylees). States may extend the bar on eligibility for
Medicaid and Medicaid-expansion SCHIP programs until
immigrants have worked continuously for 40 quarters or
become naturalized citizens, whichever occurs first. States
cannot, however, impose these additional limits on eligibility
for SCHIP programs that are operated independently of
Medicaid.
seven years in the U.S. After seven years, they lose SSI
unless they become naturalized citizens. Because SSI
eligibility is a pathway to Medicaid eligibility for most of these
immigrants, the loss of SSI also often means loss of
Medicaid coverage. These immigrants can, however,
maintain Medicaid eligibility if they qualify under a different
eligibility category.
New citizenship documentation requirements for
naturalized citizens. New requirements included in the
Deficit Reduction Act of 2005 will require U.S. citizens,
including naturalized citizens, to submit documents, such as
birth certificates or passports, verifying citizenship to retain
Medicaid coverage. Those naturalized citizens unable to
produce the required documentation will lose Medicaid
coverage. The citizenship verification requirements do not
apply to immigrants who are not citizens, although they must
continue to provide proof that they are legal U.S. residents.
IMPACT
The 1996 restrictions on Medicaid and SCHIP eligibility for
immigrants exacerbated the disparity in health coverage
between immigrants and native citizens and contributed to
the increasing uninsured rates among immigrants,
particularly non-citizens. Much of the decline in Medicaid
coverage among non-citizens occurred immediately following
implementation of the restrictions. Although immigrant
enrollment in Medicaid has stabilized in recent years, it
remains below that of native citizens.
The withdrawal of federal support for immigrant health
coverage shifted the burden of covering this population to
states and local safety net providers. While a number of
states, especially those with large immigrant populations,
provide state-funded coverage, the lack of federal funding
makes this coverage vulnerable to cuts during economic
downturns. As the number of immigrants living in the U.S.
continues to increase, and as these immigrants increasingly
move into states that do not provide such coverage, the
problem of uninsurance among immigrants can be expected
to worsen. In light of these trends, a continued focus on the
health coverage and health status of immigrants is needed.
Additional copies of this publication (#7492) are available on
the Kaiser Family Foundation’s website at www.kff.org.
i
Jeffery Passell, The Size and Characteristics of the Unauthorized Migrant
Population in the U.S., Pew Hispanic Center, Washington, DC: March 2006.
ii
Leighton Ku and Sheetal Matani, “Left Out: Immigrants’ Access to Health Care
and Insurance,” Health Affairs 20 (1) 2001: 249.
iii
Certain immigrants, including those who become U.S. citizens, those who have
worked continuously for 40 quarters, certain victims of domestic violence, and
those unable to obtain food or shelter after taking into account the sponsor’s
income, are exempt from sponsor deeming.
Seven-year limit on receipt of Social Security Income for
refugees and asylees. Refugees and other humanitarian
immigrants are eligible to receive SSI benefits for their first
The Kaiser Commission on Medicaid and the Uninsured provides information and analysis on health care coverage and access for the low-income population,
with a special focus on Medicaid’s role and coverage of the uninsured. Begun in 1991 and based in the Kaiser Family Foundation’s Washington, DC office, the
Commission is the largest operating program of the Foundation. The Commission’s work is conducted by Foundation staff under the guidance of a bipartisan
group of national leaders and experts in health care and public policy.