State Medicaid and SCRIP Coverage of Noncitizens

This report focuses on the laws governing noncitizen eligibility for Medicaid and the State Children's Health Insurance Program (SCHIP) and -- to the extent of available data -- implementation of these policies at the state level

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epared for Members and Committees of Congress

ŠŽȱŽ’ŒŠ’ȱŠ—ȱ ȱ˜ŸŽ›ŠŽȱ˜ȱ˜—Œ’’£Ž—œȱ
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One of the first pieces of legislation taken up by the 111th Congress—H.R. 2, the Children’s
Health Insurance Program Reauthorization Act of 2009 (CHIPRA 2009)—contains provisions
that would give states the option of providing Medicaid and State Children’s Health Insurance
Program (SCHIP) benefits to certain legal permanent residents (LPRs, i.e., foreign nationals who
live lawfully and permanently in the United States) during the first five years that they are living
in the United States. The House passed H.R. 2 on January 14, 2009. The Senate Committee on
Finance ordered reported a bill (S. 275) that also includes provisions that would give states the
option of providing Medicaid and SCHIP to certain LPRs during the first five years that they are
living in the United States. In turn, S. 275 became the substitute language for H.R. 2 when it
passed the Senate on January 29, 2009. In both bills, those who could be covered would be
children and pregnant women who are LPRs and battered individuals lawfully residing in the
United States. Both bills would prohibit federal funding under the act for individuals who are not
lawfully residing in the United States. On February 4, 2009, the House agreed to the Senate
version of H.R. 2, and President Barack Obama signed it into law as P.L. 111-3.
Under current law (prior to passage of CHIPRA 2009), most newly arriving LPRs are barred from
Medicaid and SCHIP for the first five years after entry. After five years, LPRs are eligible for
SCHIP, but their subsequent coverage for Medicaid becomes the state’s option. Those longtime
LPRs with a substantial work history—generally 10 years (40 quarters) of work documented by
Social Security or other employment records—or a military connection (active duty military
personnel, veterans, and their families) are also eligible. Medicaid coverage is required for all
otherwise qualified Supplemental Security Income (SSI) recipients, so long as they meet SSI
noncitizen eligibility tests. The enactment of current law on noncitizen eligibility for federal
means-tested programs predates SCHIP’s passage by one year, and as a result, SCHIP’s
noncitizen eligibility rules differ from Medicaid in some instances. How this state option
provision in CHIPRA 2009 will be implemented will unfold in the coming months.
A significant exception to the five-year bar for LPRs are aliens who arrive as refugees or who
become asylees. Refugees and asylees are eligible for Medicaid until they have been in the United
States for seven years. After the initial seven years for refugees and asylees, states have the option
to continue to provide Medicaid.
In establishing eligibility of noncitizens, the Systematic Alien Verification for Entitlements
(SAVE) system provides federal, state, and local governmental agencies access to data on
immigration status that are necessary to determine eligibility for Medicaid and SCHIP.
According to the limited data that are available, it appears that a noteworthy number of states had
opted to provide Medicaid and SCHIP to LPRs during the first five years from solely state-funded
sources. According to data from the State Noncitizen Eligibility Survey (SNES), conducted by the
Congressional Research Service (CRS), many states that responded to the survey were exercising
their option to cover LPRs. Specifically, eight states (of the 28 that responded) and the District of
Columbia reported that they offered solely state-funded insurance to noncitizens that were
ineligible for Medicaid coverage as of June of 2006. Ten states and the District of Columbia
reported that they had locally funded (e.g., county) insurance plans in 2006. A study sponsored by
the Kaiser Commission on the Uninsured found that nearly half (23) of states used state-only
funds to provide coverage to legal immigrants who were ineligible for Medicaid or SCHIP in
2004.
This report will be updated to reflect legislative activity.

˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ

ŠŽȱŽ’ŒŠ’ȱŠ—ȱ ȱ˜ŸŽ›ŠŽȱ˜ȱ˜—Œ’’£Ž—œȱ
ȱ
˜—Ž—œȱ
Background ..................................................................................................................................... 1
Summary of Law Prior to Passage of CHIPRA 2009 (P.L. 111-3)............................................ 1
Noncitizen Verification ............................................................................................................. 2
Deeming and Sponsorship......................................................................................................... 3
Analysis of States’ Coverage of LPRs............................................................................................. 4
Legislative Activity in the 111th Congress ....................................................................................... 9
Legislation................................................................................................................................. 9
Summary of the Debate........................................................................................................... 10

’ž›Žœȱ
Figure 1. State and Locally Funded Medical Insurance for Otherwise Ineligible
Noncitizens................................................................................................................................... 9

Š‹•Žœȱ
Table 1. State Policies on Noncitizen Eligibility for Medicaid in 2000 and 2006........................... 5
Table 2. State and Locally Funded Medical Insurance for Otherwise Ineligible
Noncitizens................................................................................................................................... 6

˜—ŠŒœȱ
Author Contact Information ...........................................................................................................11

˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ

ŠŽȱŽ’ŒŠ’ȱŠ—ȱ ȱ˜ŸŽ›ŠŽȱ˜ȱ˜—Œ’’£Ž—œȱ
ȱ
ŠŒ”›˜ž—ȱ
As Congress debated extending the funding of the State Children’s Health Insurance Program
(SCHIP), immigrant eligibility was one of the more controversial elements. On February 4, 2009,
President Barack Obama signed H.R. 2, the Children’s Health Insurance Program Reauthorization
Act of 2009 (CHIPRA 2009), into law as P.L. 111-3. Over a decade ago, Title IV of the Personal
Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 (P.L. 104-193)
established comprehensive restrictions on the eligibility of all noncitizens for federal means-
tested public assistance, with exceptions for legal permanent residents (LPRs) with a substantial
U.S. work history or military connection.1 Prior to 1996, LPRs were not categorically barred from
federal assistance programs. These laws and policies are discussed extensively in other CRS
products.2 This report focuses on the laws governing noncitizen eligibility for Medicaid and the
State Children’s Health Insurance Program (SCHIP) and – to the extent data are available –
implementation of these policies at the state-level. Because PRWORA predates SCHIP by one
year, SCHIP’s noncitizen eligibility rules differ somewhat from Medicaid, as noted below.3
ž––Š›¢ȱ˜ȱŠ ȱ›’˜›ȱ˜ȱŠœœŠŽȱ˜ȱ ȱŘŖŖşȱǻǯǯȱŗŗŗȬřǼŚȱ
Under current law (prior to passage of CHIPRA 2009), most newly arriving LPRs are barred from
Medicaid and SCHIP for the first five years after entry. After five years, LPRs are eligible for
SCHIP, but their subsequent coverage for Medicaid becomes the state’s option. Longtime LPRs
resident as of August 22, 1996 are allowed Medicaid at state option. Those LPRs with a
substantial work history—generally 10 years (40 quarters) of work documented by Social
Security or other employment records—or a military connection (active duty military personnel,
veterans, and their families) are also eligible. Medicaid coverage is required for all otherwise
qualified Supplemental Security Income (SSI) recipients, so long as they meet SSI noncitizen
eligibility tests.
A significant exception to the five-year bar for LPRs are aliens who arrive as refugees or who
become asylees. Refugees and asylees are eligible for Medicaid until they have been in the United
States for seven years. After the initial seven years for refugees and asylees, states have the option
to continue to provide Medicaid.5

1 Legal permanent residents (LPRs) refer to foreign nationals who live lawfully and permanently in the United States.
2 For further discussion of legal permanent residents’ eligibility, see CRS Report RL33809, Noncitizen Eligibility for
Federal Public Assistance: Policy Overview and Trends
, by Ruth Ellen Wasem, and CRS Report RL34500,
Unauthorized Aliens’ Access to Federal Benefits: Policy and Issues, by Ruth Ellen Wasem. For background on
Medicaid and SCHIP, see CRS Report RL30473, State Children's Health Insurance Program (SCHIP): A Brief
Overview
, by Elicia J. Herz, Chris L. Peterson, and Evelyne P. Baumrucker, and CRS Report RL33202, Medicaid: A
Primer
, by Elicia J. Herz.
3 SCHIP, which is title XXI of the Social Security Act, was established as title IV of the Balanced Budget Act of 1997,
P.L. 105-33.
4 It is premature to discuss how §214 of CHIPRA 2009 will be implemented.
5 When LPRs naturalize as U.S. citizens, they are afforded the same benefits as all U.S. citizens have. See CRS Report
RL33809, Noncitizen Eligibility for Federal Public Assistance: Policy Overview and Trends.
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
ŗȱ

ŠŽȱŽ’ŒŠ’ȱŠ—ȱ ȱ˜ŸŽ›ŠŽȱ˜ȱ˜—Œ’’£Ž—œȱ
ȱ
Regarding nonimmigrants and unauthorized aliens,6 §401 of PRWORA bars them from any
federal public benefit except the emergency services and programs expressly listed in §401(b) of
PRWORA. Treatment under Medicaid for emergency medical conditions (other than those related
to an organ transplant) is one of the statutory exceptions to the bar.7 PRWORA mandated that
unauthorized alien women be ineligible for prenatal care under Medicaid. In Lewis v. Thompson,
the court found that citizen children of unauthorized alien mothers must be accorded automatic
eligibility on terms as favorable as those available to the children of citizen mothers.8
SCHIP is considered a federal public benefit that statutorily bars unauthorized aliens and
nonimmigrants.9 The U.S. Department of Health and Human Services promulgated regulations in
2002 permitting states to provide SCHIP coverage to “unborn children,” i.e., fetuses.10 States
reportedly are using this option of SCHIP coverage for fetuses to provide prenatal care services to
pregnant women who are unauthorized aliens.
˜—Œ’’£Ž—ȱŽ›’’ŒŠ’˜—ȱ
The laws governing the eligibility of LPRs for means-tested federal assistance such as Medicaid
and SCHIP are based on a complex set of factors (e.g., work history, category of admission, and
petitioning sponsorship). As a consequence, determining a person’s immigration and citizenship
status is not always easy. The technology to verify legal immigration status has advanced
considerably over the years.11
In addition to drawing on documentary evidence provided by the person seeking Medicaid and
SCHIP, the Systematic Alien Verification for Entitlements (SAVE) system provides federal, state,
and local governmental agencies access to data on immigration status that are necessary to
determine noncitizen eligibility for public benefits. The U.S. Citizenship and Immigration Service
(USCIS) does not determine benefit eligibility; rather SAVE enables the specific program
administrators to ensure that only those noncitizens who meet their program’s eligibility rules
actually receive public benefits. SAVE’s statutory authority dates back to the Immigration Reform
and Control Act of 1986 (IRCA, P.L. 99-603). The IRCA, as amended, mandates the Medicaid

6 Nonimmigrants are foreign nationals admitted for a temporary period of time and a specific purpose. The three main
components of the unauthorized resident alien population are (1) aliens who overstay their nonimmigrant visas, (2)
aliens who enter the country surreptitiously without inspection, and (3) aliens who are admitted on the basis of
fraudulent documents.
7 §401(c) of PRWORA, 8 U.S.C. 1611.
8 Lewis v. Thompson, 252 F.3d 567, 588 (2d. Cir. 2001). For a complete analysis, see CRS Report RS21470,
Noncitizen Eligibility For Major Federal Public Assistance Programs: Legal Concepts, by Alison M. Smith.
9 § 401(c) of PRWORA [8 U.S.C. 1611 ] defines federal public benefit as “any grant, contract, loan, professional
license, or commercial license provided by an agency of the United States or by appropriated funds of the United
States; and any retirement, welfare, health, disability, public or assisted housing, postsecondary education, food
assistance, unemployment benefit, or any other similar benefit for which payments or assistance are provided to an
individual, household, or family eligibility unit by an agency of the United States or by appropriated funds of the
United States.” See also U.S. Department of Health and Human Services and Department of Justice, “Personal
Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA): Federal Benefit Interpretation; Notice
of Eligibility for Federal Public Benefits Verification,” 63 Federal Register 41658, August 4, 1998
10 Fed. Reg. v. 67, pp. 61955–74, Oct. 2, 2002.
11 CRS Report RL34007, Immigration Fraud: Policies, Investigations, and Issues, by Ruth Ellen Wasem, pp. 10-12.
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
Řȱ

ŠŽȱŽ’ŒŠ’ȱŠ—ȱ ȱ˜ŸŽ›ŠŽȱ˜ȱ˜—Œ’’£Ž—œȱ
ȱ
program (along with other federal programs) to participate in the verification of an applicant’s
immigration status.12
In 1996, PRWORA broadened the verification requirement to include persons applying for all
federal public benefits, 13 which would encompass SCHIP when it was enacted the following year
because it is considered a federal public benefit.14 Those states that run SCHIP through Medicaid
are required to use SAVE. Those states that opt for their own variant of SCHIP are required to use
a verification system similar to SAVE (referenced in §432 of PRWORA as similar to §1137 of
SSA) or may use SAVE.15
ŽŽ–’—ȱŠ—ȱ™˜—œ˜›œ‘’™ȱ
For LPRs (but not refugees and asylees), the law links the income of the person who sponsored
the alien to immigrate to the United States with the immigrant’s income calculations when
determining eligibility for most federal benefits. The basis of this policy is that the Immigration
and Nationality Act excludes immigrants who appear “likely at any time to become a public
charge.”16 This exclusion is implemented by provisions on deeming sponsors’ income and binding
affidavits of support. Not all prospective LPRs are required to have affidavits of support to
demonstrate that they will not become a public charge, and most exceptions are statutory (e.g.,
refugees or employment-based LPRs).17
The affidavit of support is a legally binding contract that requires the sponsor to ensure that the
new immigrant will not become a public charge and to make the sponsor financially responsible
for the new immigrant, as codified in § 213A of the Immigration and Nationality Act (INA).18
Sponsors must demonstrate the ability to maintain an annual income of at least 125% of the
federal poverty line (100% for sponsors who are on active duty in U.S. Armed Forces); or share
liability with one or more joint sponsors, each of whom must independently meet the income
requirement. Current law also directed the federal government to include “appropriate
information” regarding affidavits of support in the SAVE system. Congress has required the
establishment of an automated record of the sponsors’ social security numbers (SSN) in order to
implement this policy. 19

12§1137 of the Social Security Act as amended by P.L. 99-603 and P.L. 104-193.
13 P.L. 104-193, § 432.
14 U.S. Department of Health and Human Services and Department of Justice, “Personal Responsibility and Work
Opportunity Reconciliation Act of 1996 (PRWORA): Federal Benefit Interpretation; Notice of Eligibility for Federal
Public Benefits Verification,” 63 Federal Register 41658, August 4, 1998.
15 8 U.S.C 1642(a)(1). The U.S. Department of Health and Human Services’ Centers for Medicare and Medicaid
Services has an undated “Questions and Answers Guidance” that addresses these matters, which is available on their
website at [http://www.cms.hhs.gov/MedicaidEligibility/Downloads/alien2.pdf ].
16 The colony of Massachusetts enacted legislation in 1645 prohibiting the entry of paupers, and in 1700 excluding the
infirm unless security was given against their becoming public charges. New York adopted a similar practice. A bar
against the admission of “any person unable to take care of himself or herself without becoming a public charge” was
included in the act of August 3, 1882, the first general Federal immigration law. It is now §212 (a)(4) of the INA; 8
U.S.C. 1182.
17 Employment-based LPRs, for example, meet the public charge ground by means of the job offer and only need an
affidavit of support if the prospective employer is a relative. 8 C.F.R. § 213a.1.
18 § 213A of INA; 8 U.S.C. 1631. Fed. Reg., v, pp. 54346-56. Oct. 20, 1997.
19 § 213A of INA; 8 U.S.C. 1631.
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
řȱ

ŠŽȱŽ’ŒŠ’ȱŠ—ȱ ȱ˜ŸŽ›ŠŽȱ˜ȱ˜—Œ’’£Ž—œȱ
ȱ
According to administrative guidance issued in 1999, the receipt of Medicaid or SCHIP does not
trigger the deportation or removal of a noncitizen beneficiary. It also does not categorically
prevent them from sponsoring a potential LPR. The cash benefit, however, cannot be included in
the calculation of the beneficiary’s income if they sign an affidavit of support for a potential
LPR.20
Under the deeming rules, all of the income and resources of a sponsor (and a sponsor’s spouse)
may be deemed available to the sponsored applicant for assistance until the noncitizen becomes
naturalized or meets a work test.21 The INA requires states to seek reimbursement of the costs of
federal means-tested benefits from the sponsors. The sponsor’s liability ends when the sponsored
alien is no longer subject to deeming, either through naturalization or meeting a work test.22
SCHIP was enacted after the list of programs meeting the PRWORA designation of federal means
tested programs was proposed.23
—Š•¢œ’œȱ˜ȱŠŽœȂȱ˜ŸŽ›ŠŽȱ˜ȱœȱ
As noted above, states have the authority to provide Medicaid to LPRs following the initial five-
year bar, and it appears that many states have opted to do so. According to data from the State
Noncitizen Eligibility Survey (SNES), conducted by the Congressional Research Service (CRS),
most states that responded to the survey were exercising their option to cover LPRs.24 Table 1
summarizes these policies that the states reported.



20 A 1999 memorandum stated that the “receipt of Medicaid or CHIP benefits will not be considered in making a public
charge determination, except in the case of an alien who is primarily dependent on the government for subsistence as
demonstrated by institutionalization for long-term care at government expense. This exception will not include short-
term rehabilitation stays in long-term care facilities.” The guidance further provided that the receipt of Medicaid or
CHIP benefits would not disqualify an LPR from sponsoring other immigrants, i.e., signing an affidavit of support for a
prospective LPR. U.S. Department of Health and Human Services, Health Care Financing Administration, Center for
Medicaid and State Operations, letter to State Health Officials, May 26, 1999.
21 § 421 of PRWORA. Also in 8 USC 1631.
22 § 213A of INA; 8 U.S.C. 1631.
23 Fed. Reg. v. 62, pp. 45256-58, Aug. 26, 1997.
24 The data analyzed in this report are from the 2003 and 2006 self-reported State Noncitizen Eligibility Survey (SNES)
conducted by Congressional Research Service (CRS). CRS Graduate Intern Robynn Cox prepared the data analysis of
the 2003 and 2006 SNES data that are used in this report. The survey asks numerous questions about the various states’
noncitizen eligibility policies in December of 2000, December of 2002, December of 2004, and June of 2006. All 50
states, the District of Colombia, American Samoa, Guam, Puerto Rico, U.S. Virgin Islands, and the Northern Mariana
Islands were asked to participate in the questionnaire. Six states and 2 territories did not respond in 2003. There were
22 states and all 5 territories that did not respond in 2006, which obviously limits the usefulness of the data from the
2006 SNES survey.
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
Śȱ

ŠŽȱŽ’ŒŠ’ȱŠ—ȱ ȱ˜ŸŽ›ŠŽȱ˜ȱ˜—Œ’’£Ž—œȱ
ȱ
Table 1. State Policies on Noncitizen Eligibility for Medicaid in 2000 and 2006
2000 2006
Total States Responding 47 States, the District of Columbia, 28 States and the District of
and 3 Territories Responded
Columbia Responded
LPRs present in the U.S.
40 States, the District of Columbia, and
28 States and the District of Columbia
before 8/22/96 were eligible the U.S. Virgin Islands
for Medicaid at state option?
LPRs, parolees, and victims
33 States, 3 Territories, and the District of 25 States and the District of Columbia
of abuse present on or after Columbia
8/22/96 were eligible for
Medicaid after the federal
bar expired?
Noncitizens admitted on
32 States, the District of Columbia, and
23 States and the District of Columbia
humanitarian grounds were
the U.S. Virgin Islands
eligible for Medicaid at state
option after federal eligibility
period expired?
State offered state funded
15 States and the District of Columbia
8 States and the District of Columbia
insurance plans to cover
noncitizens not eligible for
Medicaid or SCHIP?
State offered locally funded
15 States and the District of Columbia
10 States and the District of Columbia
insurance plans to cover
noncitizens not eligible for
Medicaid of SCHIP?
State deemed immigrant
5 States
16 States
sponsor income or
resources?
State tracked immigrant
0 States
1 State
sponsors to enforce
reimbursement?
State had policy to collect
0 States
1 State
government reimbursement
under accountability rule?
Source: CRS State Noncitizen Eligibility Survey, 2003 and 2006. CRS Graduate Intern Robynn Cox prepared the
data analysis of the 2000 and 2006 SNES data that are used in this table.
As noted above, states are required to deem the income of the LPRs’ sponsor, i.e., the person or
entity that signed the affidavit of support. In 2004 and 2006, there were 16 states that reported
deeming the immigrant sponsors’ income compared to 5 states in 2000. The 16 states that
reported deeming immigrant sponsors’ income in the 2006 SNES are: Alaska, Arkansas,
Connecticut, Hawaii, Minnesota, Montana, Nebraska, New Mexico, North Carolina, Ohio,
Oregon, Texas, Utah, Vermont, Washington, and West Virginia.
In addition to providing SCHIP and the option of providing Medicaid, eight states and the District
of Columbia reported that they offered solely state-funded insurance to noncitizens that were
ineligible for Medicaid coverage as of June of 2006. Ten states and the District of Columbia
reported that they had locally (e.g. county) funded insurance plans. The set of states offering
solely state-funded insurance plans is different from those offering locally funded insurance
plans, as can be seen in Table 2.
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
śȱ

ŠŽȱŽ’ŒŠ’ȱŠ—ȱ ȱ˜ŸŽ›ŠŽȱ˜ȱ˜—Œ’’£Ž—œȱ
ȱ
Table 2. State and Locally Funded Medical Insurance for Otherwise Ineligible
Noncitizens
State offered solely state-funded
insurance plans to cover
State offered locally-funded insurance
noncitizens not eligible for Medicaid plans to cover noncitizens not eligible for
State
or SCHIP?
Medicaid or SCHIP?

2000 2002 2004 2006 2000 2002 2004
2006
Alabama
No No NR NR Yes Yes NR NR
Alaska
Yes Yes No No No No No No
American
Samoa No No NR NR No No NR NR
Arizona
No No No No Yes Yes Yes Yes
Arkansas
No No No No No No No No
California
Yes Yes NR NR No No NR NR
Colorado
NR NR NR NR NR NR NR NR
Connecticut
Yes Yes Yes Yes No No Yes Yes
Delaware
NR NR Yes Yes NR NR No No
District
of
Columbia
Yes Yes Yes Yes Yes Yes Yes Yes
Florida
No No NR NR Yes Yes NR NR
Georgia
NR NR No No NR NR No No
Guam
NR NR NR NR NR NR NR NR
Hawaii
Yes Yes Yes Yes Yes Yes No No
Idaho
No No NR NR No No NR NR
Illinois
Yes Yes NR NR No No NR NR
Indiana
No No NR NR NR NR NR NR
Iowa
No No NR NR No No NR NR
Kansas
No No No No Yes Yes Yes Yes
Kentucky
No No NR NR No No NR NR
Louisiana
No No No No No No No No
Maine
Yes Yes NR NR NR NR NR NR
Maryland
Yes Yes NR NR No No NR NR
Massachusetts Yes Yes NR NR Yes Yes NR NR
Michigan
NR NR NR NR NR NR NR NR
Minnesota
Yes Yes Yes Yes No No No No
Mississippi
No No NR NR No No NR NR
Missouri
No No No No NR NR Skip Skip
Montana
No No No No No No No No
Nebraska
Yes Yes Yes Yes Yes Yes Yes Yes
Nevada
No No NR NR No No NR NR
New
Hampshire NR NR NR NR NR NR NR NR
˜—›Žœœ’˜—Š•ȱŽœŽŠ›Œ‘ȱŽ›Ÿ’ŒŽȱ
Ŝȱ

ŠŽȱŽ’ŒŠ’ȱŠ—ȱ ȱ˜ŸŽ›ŠŽȱ˜ȱ˜—Œ’’£Ž—œȱ
ȱ
State offered solely state-funded
insurance plans to cover
State offered locally-funded insurance
noncitizens not eligible for Medicaid plans to cover noncitizens not eligible for
State
or SCHIP?
Medicaid or SCHIP?

2000 2002 2004 2006 2000 2002 2004
2006
New
Jersey
Yes Yes NR NR Yes Yes NR NR
New
Mexico
No No Yes Yes Yes Yes Yes Yes
New
York
NR NR Yes Yes NR NR Yes Yes
North
Carolina No No No No Yes Yes Yes Yes
North
Dakota No No No No No No No No
N. Mariana Islands
No
No
NR
NR
No
No
NR
NR
Ohio
No No No No Yes Yes No Skip
Oklahoma
No No NR NR No No NR NR
Oregon
No No No No No No No No
Pennsylvania
Yes Yes NR NR No No NR NR
Puerto
Rico
NR NR NR NR NR NR NR NR
Rhode
Island
Yes Yes NR NR Yes Yes NR NR
South
Carolina No No No No No No No No
South
Dakota
No No No No Yes Yes Yes Yes
Tennessee
Yes Yes NR NR No No NR NR
Texas
No No No No Yes Yes Yes Yes
Utah

No No No No No No No No
U.S. Virgin Islands
No
No
NR
NR
Yes
Yes
NR
NR
Vermont
No No No No No No No No
Virginia
No No No No No No No No
Washington
Yes Yes Yes Yes No No No No
West
Virginia No No No No No No Yes Yes
Wisconsin
No No No No No No No No
Wyoming
No No NR NR No No NR NR
Source: CRS State Noncitizen Eligibility Survey, 2003 and 2006. CRS Graduate Intern Robynn Cox prepared the
data analysis of the 2000 and 2006 SNES data that are used in this table.
NR - Did not respond to the survey for that year
Skip - State responded to the survey for that year but skipped the question
Although the SNES data are limited by the number of states that responded, the trends from the
SNES data are consistent with but not identical to other published research. In their 1997-1998
survey, Zimmerman and Tumlin found that 14 states offered state-funded Medicaid for qualified
legal immigrants during the federal five-year bar: California, Illinois, Massachusetts, Maryland,
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Virginia, Washington, Pennsylvania, Connecticut, Minnesota, Hawaii, Rhode Island, Nebraska,
Delaware, and Maine.25
According to a Fremstad and Cox study sponsored by the Kaiser Commission on the Uninsured,
nearly half (23) of states used state funds to provide coverage to legal immigrants who are
ineligible for Medicaid or SCHIP in 2004. Fremstad and Cox also found seven states, including
two states that do not provide any state-funded coverage for immigrants, opted to provide SCHIP-
funded coverage for prenatal care regardless of the immigration status of the mother.26
Figure 1 integrates the 2004 Kaiser state survey conducted by Fremstad and Cox with the 2006
SNES data gathered by CRS into a map of the United States. Obviously both of these surveys
were conducted before the economic recession and the resulting financial budgetary problems
that the states are experiencing.

25 Urban Institute, Patchwork Policies: State Assistance for Immigrants Under Welfare Reform, by Wendy Zimmerman
and Karen C.. Tumlin, Occasional Paper Number 24, (1999). Twelve of the 14 states in the Zimmerman and Tumlin
survey that offered state-funded Medicaid for qualified legal immigrants during the five year ban are included in the 16
states that offer State-funded health insurance to noncitizens who do not qualify for federal assistance in the CRS’
survey. Delaware did not respond to the survey, and Virginia replied that they do not offer state-funded health
insurance. In addition, Alaska, Tennessee, New Jersey, and the District of Columbia responded that they did not offer
state-funded assistance for Medicaid to post-enactment qualified legal immigrants in the Zimmerman and Tumlin
survey, but responded that they did offer unqualified noncitizens state-funded insurance in the CRS survey.
26Kaiser Commission o n t h e Uninsured, Covering New Americans: A Review of Federal and State Policies Related to
Immigrants’ Eligibility and Access to Publicly Funded Health Insurance,
by Shawn Fremstad and Laura Cox, Center
on Budget and Policy Priorities, (2004).
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Figure 1. State and Locally Funded Medical Insurance for Otherwise Ineligible
Noncitizens
2004 Kaiser Study and 2006 SNES Study

Source: 2006 data from the CRS State Noncitizen Eligibility Survey (SNES) and 2004 data from the Fremstad
and Cox study sponsored by the Kaiser Commission on the Uninsured.
Notes: States that are white/blank either did not respond or responded that they did not provide such
coverage.
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One of the first pieces of legislation taken up by the 111th Congress – H.R. 2, the Children’s
Health Insurance Program Reauthorization Act of 2009 (CHIPRA 2009) – contains provisions
that would give states the option of providing Medicaid and SCHIP to certain LPRs who have
been in the United States less than five years. This option to expand immigrant eligibility is
among the legislation’s most controversial provisions.
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The Children’s Health Insurance Program Reauthorization Act of 2009 (H.R. 2) contains
provisions that would give states the option of providing Medicaid and SCHIP to LPRs during the
first five years that they are living in the United States. As passed by the House on January 14,
2009 §214 of H.R. 2 would allow states to waive—for children and pregnant women who are
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LPRs and battered individuals lawfully residing in the United States—four elements of current
law: the statutory bar, the limited eligibility provision, the five-year bar, and the deeming of
sponsors’ assets.27 In addition, the bill would waive the sponsor’s financial responsibility for
Medicaid and SCHIP provided to individuals covered under this provision by amending the
underlying language in §423 of PRWORA that pertains to §213A of the INA.28 The
Congressional Budget Office (CBO) estimates that the changes in §214 would increase direct
spending under Medicaid by $3.9 billion over the 2009-2019 period.29
On January 15, 2009, the Senate Committee on Finance ordered a Chairman’s mark reported as
amended (S. 275) to include provisions that also would give states the option of providing
Medicaid and SCHIP to children and pregnant women who are LPRs and battered individuals
(described in section 431(c) of PRWORA) lawfully residing in the United States during the first
five years that they are living in the United States. While similar to §214 of H.R. 2, the Senate bill
differs in a few instances. Although it does not directly amend the subsection of the INA that
makes the sponsor financially responsible for the LPR, §214 of S. 275 might offer a similar
outcome for individuals covered under this provision. As reported by the Senate Finance
Committee, §214 states: “no debt shall accrue under an affidavit of support against any sponsor of
such an alien on the basis of provision of assistance to such category and the cost of such
assistance shall not be considered as an unreimbursed cost.”30 Lastly, S. 275 would require the
states to determine that individuals covered by §214 continue to be in lawful resident status as
part of the state’s ongoing eligibility redetermination requirements and procedures (i.e., to
redetermine eligibility at least every 12 months with respect to circumstances that may change
and affect eligibility). When the Senate took up CHIPRA, S. 275 became the substitute language
for H.R. 2, and it passed the Senate on January 29, 2009.
Both bills prohibit federal funding under the act for individuals who are not lawfully residing in
the United States.31
On February 4, 2009, the House agreed to the Senate version of H.R. 2, and President Barack
Obama signed CHIPRA 2009 into law as P.L. 111-3. It premature to discuss how §214 of
CHIPRA 2009 will be implemented, but will likely unfold in the coming months.
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Proponents of allowing Medicaid and SCHIP eligibility for LPR children and pregnant LPRs
during their first five years in the United States make several arguments. Foremost, advocates

27 The provisions that would be waived by § 214 of H.R. 2 respectively are §§ 401(a), 402(b), 403, and 421 of
PRWORA. For further discussion of these specific provisions, see CRS Report RL33809, Noncitizen Eligibility for
Federal Public Assistance: Policy Overview and Trends
.
28 §214(d) of H.R. 2 as passed by the House.
29 U.S. Congressional Budget Office, H.R. 2 Children’s Health Insurance Program Reauthorization Act of 2009 As
transmitted to CBO by the House Committee on Energy and Commerce on January 13, 2009.
Jan. 13, 2009.
30 According to the legislative language, the provision applies only to LPRs provided SCHIP and Medicaid under §214
of this Act.
31 Except for a narrow set of specified emergency services and programs, unauthorized aliens are not eligible for
federal public benefits. One the exceptions in current law, however, is emergency Medicaid. See CRS Report
RL34500, Unauthorized Aliens’ Access to Federal Benefits: Policy and Issues, by Ruth Ellen Wasem; and CRS Report
RL31630, Federal Funding for Unauthorized Aliens' Emergency Medical Expenses, by Alison Siskin.
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ŗŖȱ

ŠŽȱŽ’ŒŠ’ȱŠ—ȱ ȱ˜ŸŽ›ŠŽȱ˜ȱ˜—Œ’’£Ž—œȱ
ȱ
note that LPRs are legal residents who work and pay taxes; as a result, they contend, they should
be able to draw on the federal Medicaid and SCHIP programs if need arises or misfortunes occur.
They argue further that the use of Medicaid and SCHIP by LPR children and pregnant LPRs
should not be considered a public charge and distinguish the need for health care from welfare
dependency. A third important argument relates to the perceived complexity of the current
eligibility rules for noncitizens. Advocates maintain that the rules are so complex (varying as they
do among programs and classes of noncitizens) that many eligible noncitizens are discouraged
from applying.
Supporters of current law maintain that LPRs and their sponsors should take responsibility for the
LPR’s support and not expect the federal government to do so. They often reference the public
charge ground for exclusion of immigrants and argue that the United States should not admit
LPRs if they do not have the financial means, employment skills, or the family resources to
support themselves. Finally, they maintain that U.S. citizens and longtime LPRs should be
prioritized for Medicaid and SCHIP eligibility before recently arriving LPRs gain access.

ž‘˜›ȱ˜—ŠŒȱ —˜›–Š’˜—ȱ

Ruth Ellen Wasem

Specialist in Immigration Policy
rwasem@crs.loc.gov, 7-7342




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