Noncitizen Eligibility for Medicaid and CHIP

Noncitizen Eligibility for Medicaid and CHIP

August 25, 2021
Noncitizen Eligibility for Medicaid and CHIP
Medicaid and the State Children’s Health Insurance
discretion in determining certain eligibility criteria for both
Program (CHIP) provide a health care safety net for low-
mandatory and optional eligibility groups, which results in
income populations. The availability of these programs for
substantial variability across states. Under CHIP, states
noncitizens (i.e., aliens in immigration law) depends on the
have broad discretion in setting their income eligibility
noncitizen’s immigration status and certain other factors.
standards, and eligibility varies by state.
The Migration Policy Institute estimates 2.4 million low-
income noncitizens were enrolled in Medicaid, CHIP, or
Medicaid and CHIP applicants must also meet federal and
another public health insurance program in 2019. This In
state requirements regarding
Focus provides an overview of Medicaid/CHIP eligibility
 State Residency: SSA §§1902(a)(16), 1902(a),
rules for non-U.S. citizens.
1902(b)(2) and 2102(b)(1)(A) [42 U.S.C.
Medicaid and CHIP Background
§§1396a(a)(16), 1396a(a), 1396a(b)(2) and
1397bb(b)(1)(A)];
Medicaid, authorized in Title XIX of the Social Security
Act (SSA), is a joint federal-state program that finances the
 Documentation of U.S. Citizenship: SSA
delivery of primary and acute medical services—as well as
§§1137(d)(2), 1902(a)(46), 1902(ee), 1903(x) and
long-term services and supports—to a diverse, low-income
2105(c)(9)(A) [42 U.S.C. §§1320b-7(d)(2),
population, including children, pregnant women, adults,
1396a(a)(46), 1396a(ee), 1396b(x) and
individuals with disabilities, and people aged 65 and older.
1397ee(c)(9)(A)]; and
CHIP, authorized in SSA Title XXI, provides health

insurance coverage to low-income, uninsured children in
Immigration Status: SSA §§1902(b)(3) and
families with incomes above applicable Medicaid income
2105(a)(3)(F) [42 U.S.C. §§1396a(b)(3) and
standards, as well as to certain pregnant women.
1397ee(a)(3)(F)]; and Personal Responsibility and Work
Participation in both programs is voluntary for states,
Opportunity Reconciliation Act of 1996 (PRWORA;
though all states, the District of Columbia, and the U.S.
P.L. 104-193), as amended §§401, 402, 403, 421 and
431 [8 U.S.C. §§1611, 1612, 1613, 1631, 1641].
territories (i.e., American Samoa, the Commonwealth of the
Northern Mariana Islands [CNMI], Guam, Puerto Rico, and
While most Medicaid and CHIP eligibility rules reside
the U.S. Virgin Islands) choose to participate.
within SSA Titles XIX and XXI, noncitizen eligibility for
these programs is largely governed by provisions within (1)
States must follow broad federal rules to receive federal
SSA Title XI and (2) PRWORA, as amended. The
matching funds, but they have flexibility to design their
intersection of these laws establish the rules for noncitizen
own versions of Medicaid and CHIP within the federal
eligibility under Medicaid and CHIP, as summarized below.
statute’s basic framework. The U.S. territories operate their
Medicaid and CHIP programs under rules that differ from
Medicaid and CHIP Noncitizen Eligibility
those applicable to the 50 states and DC (e.g., capped
Rules
Medicaid funding, eligibility flexibilities). Both programs
Noncitizens’ eligibility for Medicaid and CHIP largely
include several statutory waiver and demonstration
depends on (1) an applicant’s immigration status; (2)
authorities that allow states to operate their programs
whether they arrived in the United States (or were enrolled
outside of certain federal rules. This flexibility results in
in Medicaid) before August 22, 1996 (the date PRWORA
variability across state Medicaid and CHIP programs in
was enacted); and (3) how long they have lived and worked
factors such as eligibility and covered benefits.
in the United States. In addition, alien applicants must meet
Medicaid and CHIP Eligibility
the programs’ other eligibility requirements (e.g., financial,
categorical, state residency).
There are a number of eligibility pathways through which
individuals may qualify for Medicaid. (An eligibility
Qualified and Nonqualified Aliens
pathway is the specific federal statutory reference[s] that
With respect to an applicant’s immigration status,
extends Medicaid coverage to certain groups of
generally, noncitizen eligibility for most federal public
individuals.) Often an applicant’s eligibility pathway
benefits—including Medicaid and CHIP—is governed by
dictates the Medicaid state plan services to which a given
the term qualified alien (8 U.S.C. §1641), which was
program enrollee is entitled. In general, individuals must
created in PRWORA, as amended. Qualified aliens include
meet both categorical (e.g., children, pregnant women) and
lawful permanent residents (LPRs), refugees, aliens paroled
financial (i.e., income and sometimes assets limits) criteria.
into the United States for at least one year, aliens granted
Some eligibility pathways are mandatory, meaning that all
asylum or related relief, certain abused spouses and
states with a Medicaid program must cover them; others are
children, and Cuban-Haitian entrants. (For more
optional. Subject to federal minimum standards, states have
information on these statuses, see CRS Report R46697,
https://crsreports.congress.gov

link to page 2 Noncitizen Eligibility for Medicaid and CHIP
Noncitizen Eligibility for Supplemental Security Income
to qualified aliens receiving Supplemental Security Income
(SSI).) Citizens of the Freely Associated States (FAS)
(SSI) on or after August 22, 1996 (8 U.S.C. §1612). States
residing in the U.S. states and territories are qualified aliens
may choose to cover LPRs within the five-year bar period
but only with respect to Medicaid (see text box below).
and other ineligible foreign nationals (i.e., nonqualified
Certain victims of human trafficking and Iraqi and Afghan
aliens) using state-only funds for individuals, services not
special immigrants are not qualified aliens but are treated
otherwise covered under Medicaid or CHIP, or both.
like refugees for purposes of federal public benefits.
Otherwise eligible qualified aliens must be covered by
Refugees and asylees are eligible for Medicaid for the first
Medicaid and CHIP, with certain specified restrictions,
seven years after arrival (8 U.S.C. §1612). (Subsequently,
discussed below (42 C.F.R. §435.306).
they may be eligible for Medicaid at the state’s option.)
Nonimmigrants, those with Temporary Protected Status
Medicaid and CHIP Exceptions for Nonqualified
(TPS), short-term (less than one year) parolees, asylum
Aliens
applicants, those granted Deferred Action for Childhood
Three exceptions allow nonqualified aliens to be eligible for
Arrivals (DACA), unauthorized immigrants, and various
Medicaid and CHIP:
other classes of noncitizens granted temporary permission
to remain in the United States are nonqualified aliens.
 Emergency Medicaid. Under emergency Medicaid
These statuses and are generally barred from Medicaid and
(§1903(v)(3) [42 U.S.C. §1396b(v)(3) and 8 U.S.C.
CHIP (8 U.S.C. §1611), with three exceptions (see
§1611(b)(1)(A)], states are required to provide limited
“Medicaid and CHIP Exceptions for Nonqualified Aliens”).
Medicaid services for the treatment of an emergency
medical condition to otherwise eligible aliens, regardless
Medicaid Eligibility for Citizens of the Freely
of immigration status or lack of immigration status. For
Associated States (FAS)
pregnant women, emergency Medicaid includes services
In the 1980s and 1990s, the Republic of the Marshal Islands,
covered under the state plan (e.g., routine prenatal care,
the Federated States of Micronesia, and the Republic of Palau
labor and delivery, and routine postpartum care) (42
signed Compacts of Free Association (COFA) with the United
C.F.R. §440.255(b)(2)).
States. FAS citizens are afforded certain immigration-related
 CHIP Unborn Child Option. In 2002, the U.S.
benefits that permit them to live, study, and work in the United
Department of Health and Human Services,
States. Since the compacts went into effect, thousands of FAS
promulgated regulations to revise the definition of child
migrants have established residence in U.S. states and
to include fetuses for the purposes of the CHIP program
territories. Prior to 1996, FAS citizens residing in the United
(42 C.F.R. §457.10). This change allows states to
States were eligible for federal public benefits. However,
provide CHIP coverage to unborn children. Since
PRWORA (P.L. 104-193) barred FAS citizens, among others,
fetuses do not have an immigration status, states use this
from most federal public benefits, such as Medicaid, the
option to provide prenatal care services to pregnant
Supplemental Nutrition Assistance Program, and Supplemental
women, regardless of their age or immigration status.
Security Income (SSI).
According to the Medicaid and CHIP Payment and
The Consolidated Appropriations Act, 2021 (P.L. 116-260)
Access Commission, 17 states provided CHIP coverage
modifies PRWORA by adding FAS citizens who are lawful y
to unborn children, as of April 2020.
residing in the United States under COFA to the list of
qualified aliens, but only with respect to Medicaid. This law
 Medicaid and CHIP Coverage of Lawfully Residing
requires the 50 states and DC to add FAS citizens as a
Children & Pregnant Women. The State Children’s
mandatory Medicaid eligibility pathway and permits the
Health Insurance Program Reauthorization Act of 2009
governors of the U.S. territories to elect to extend Medicaid
(CHIPRA; P.L. 111-3) option allows states to provide
eligibility to FAS citizens who are lawful y residing in their
Medicaid and CHIP coverage to certain “lawfully
respective territories. In the territories that make this election,
residing” children and/or pregnant women who would
FAS citizens are considered a new Medicaid mandatory
otherwise be eligible for coverage through these
eligibility pathway. In addition, Medicaid services provided to
programs within the five-year bar when certain
program enrol ees eligible through this pathway are not subject
conditions are met. (CMS has broadly defined lawfully
to the annual federal Medicaid capped funding that is otherwise
residing to include qualified aliens , aliens in valid
applicable in each such territory. According to the Centers for
nonimmigrant statuses, and many quasi-legal
Medicare & Medicaid Services (CMS), CNMI and Guam
populations, such as TPS holders and DACA recipients.)
expanded eligibility to FAS citizens, as of August 23, 2021.
According to CMS, as of December 11, 2019, 34 states,

DC, and 3 U.S. territories extend Medicaid coverage to
Eligibility Restrictions for Qualified Aliens
lawfully residing children, and 28 states cover such
There are additional Medicaid eligibility restrictions for
children under CHIP. Twenty-four states, DC, and three
qualified aliens. Many qualified aliens are prohibited from
U.S. territories extend Medicaid coverage to lawfully
receiving Medicaid for the first five years after entry/grant
residing pregnant women, and four states cover such
of status (often referred to as the five-year bar), such as
individuals under CHIP.
LPRs entering the United States after August 22, 1996 (8
U.S.C. §1613). However, other qualified aliens are exempt
Evelyne P. Baumrucker, Specialist in Health Care
from the five-year bar, including LPRs with a substantial
Financing
(i.e., 10-year) U.S. work history or a military connection (8
Abigail F. Kolker, Analyst in Immigration Policy
U.S.C. §1612). Similarly, the five-year bar does not apply
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Noncitizen Eligibility for Medicaid and CHIP

IF11912

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