Health Insurance Affordability Programs’ Eligibility Based on Immigration Status

Updated June 2024

Medicaid, the Children’s Health Insurance Program (CHIP), and the Affordable Care Act marketplaces have immigration-related restrictions that block many people from obtaining health coverage through these programs. These eligibility restrictions are complex, program-specific and in some cases vary by state. The questions and answers below seek to clarify these eligibility rules.

Note: In May 2024, the Department of Health and Human Services finalized a rule that will newly allow people with Deferred Action for Childhood Arrivals (DACA) and people with certain other immigration statuses to enroll in ACA marketplace coverage beginning November 1, 2024. We will update this resource to reflect those changes when the new policy is in place.

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What are the immigration-related eligibility requirements for Medicaid and CHIP? 

The general rules related to eligibility based off immigration status for Medicaid and CHIP are grounded in the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996. PRWORA restricted eligibility for many people who are immigrants by creating two categories of immigration statuses used in determining eligibility for public benefits: “qualified” and “not qualified”. In general, people who are immigrants must be in a qualified status to be eligible for Medicaid and CHIP. However, even people with qualified immigration statuses may not be eligible because the law also created a five-year waiting period for many people who have qualified immigration statuses. Hospitals and other medical providers may be able to get payment from Medicaid when they provide life-saving medical care to individuals who are ineligible for Medicaid due to their immigration status, but meet all other eligibility criteria. Some people who don’t meet the restrictive immigration-related requirement for Medicaid and CHIP may be eligible for subsidized ACA marketplace coverage. Additionally, states have the option to adopt broader immigration-related eligibility rules for children and pregnant people.

Which categories of immigration statuses are “qualified” for the purposes of Medicaid and CHIP eligibility? 

Categories of immigration statuses include:

• Lawful Permanent Resident status (LPR, or green card holders)
• People granted refugee status, asylum, withholding of deportation/removal, or conditional entrants
• Cuban/Haitian entrants
• Individuals paroled by the Department of Homeland Security (DHS), for a period of at least one year
• Certain domestic violence survivors and their children and/or parents
• Certain trafficking survivors and in some cases their spouses and children (for adult victims) and spouses, children, parents and minor siblings (for child victims)
• Citizens of Compact of Free Association (COFA) nations residing in the U.S.

Not “qualified” statuses but meet the eligibility standard:

• Members of a Federally-recognized Indian tribe or American Indians born in Canada
• Iraqi and Afghan special immigrant visas
• Ameriasian immigrants
• Certain Ukrainian and Afghan parolees

All other immigration statuses are considered not qualified for purposes of Medicaid and CHIP eligibility.

Are people with qualified immigration statuses eligible for Medicaid or CHIP immediately upon obtaining a qualified status? 

In general, people with qualified immigration statuses who entered the U.S. on or after August 22, 1996 must wait five years after obtaining a qualified status before meeting the immigration-related eligibility requirements for Medicaid or CHIP. This is often referred to as the “five-year bar.” However, there are exceptions. People with the following eligible immigration statuses and/or circumstances do not have to meet the five-year waiting period requirement:

• People granted refugee status, asylum, withholding of deportation/removal, or conditional entrants
• Cuban/Haitian entrants
• Amerasian immigrants
• Certain trafficking survivors
• Iraqi or Afghan special immigrant status
• Citizens from COFA nations residing in the U.S.
• Members of a Federally-recognized Indian tribe or American Indians born in Canada
• Certain Ukrainian and Afghan parolees
• Veterans or individuals on active military duty and their spouse (un-remarried surviving spouse), or child
• Children and pregnant people who are lawfully residing in the U.S. (at state option)

It is important to note that a few states restrict eligibility for some adults with a qualified immigration status even after the five-year wait.^[1]

Can states have less restrictive eligibility requirements for people who are immigrants? 

Yes. States have the option to provide Medicaid and CHIP coverage to children and/or pregnant people who are lawfully residing in the U.S. (currently using the lawfully present definition used by the ACA marketplaces, see Table 1 below). The term lawfully residing includes all qualified immigration statuses, as well as many other types of immigration statuses who have permission to live or work in the United States.

Under the CHIP conception to birth option, states can use CHIP funding to provide pregnancy-related care to people who are otherwise ineligible for Medicaid and/or CHIP due to their immigration status. In addition, a growing number of states use state or local funds to provide Medicaid and CHIP to other groups, such as people who have not met the five-year bar, people with lawfully present immigration statuses who do not have a qualified status, and people without a documented immigration status.^[2]

What are the immigration-related eligibility requirements to enroll in a ACA marketplace plan? 

People must have a lawfully present immigration status to enroll in an ACA marketplace plan. (See Table 1 for a list of immigration statuses that are considered lawfully present for the purpose of marketplace eligibility). In general people permitted under the law to be in the U.S. meet the requirement, but there are some exceptions. An important exception is individuals granted deferred action under the Deferred Action for Childhood Arrivals (DACA) program. The U.S. Department of Homeland Security can grant temporary administrative relief from deportation, which is referred to as deferred action, for a variety of reasons. While individuals granted deferred action are generally eligible to enroll in marketplace coverage, people with DACA are excluded and not eligible to enroll in a marketplace plan. This will change starting November 1, 2024 when a new Department of Health and Human Services rule goes into effect and people with DACA and certain other statuses will become eligible to enroll in ACA plans and financial help to make coverage more affordable if they meet all other applicable requirements.

What are the immigration-related eligibility requirements for premium tax credits and cost sharing reductions in the ACA marketplaces? 

People with a lawfully present immigration status are eligible to purchase ACA marketplace coverage and may also qualify for premium tax credits and cost sharing reductions if they meet all other requirements such as income, tax filing status, residence, etc.

In general, only individuals with incomes above the poverty line are eligible for premium tax credits. However, individuals who have lawfully present immigration statuses and are not eligible for Medicaid because of their immigration status can qualify for premium tax credits even if their income is below the poverty line. For example, a person with a lawfully present immigration status that is not a “qualified” immigration status, such as temporary protected status, could qualify for premium tax credits even if their income is below the poverty line. The same would be true for a person with a “qualified” immigration status, such as a lawful permanent resident, who has not completed the five-year waiting period. People who are lawfully present but ineligible for Medicaid due to their immigration status may qualify for premium tax credits even if their income is below the poverty line, regardless of their state’s decision on adopting the Medicaid expansion.

How are premium tax credits calculated for people with a lawfully present immigration status and incomes below the poverty line? 

For the purposes of determining a person’s expected contribution to the cost of coverage, the portion of income they will contribute is the same as for individuals with incomes at 100 percent of the poverty line, which is zero in 2024 and 2025.^[3] Their premium tax credit will be equal to the cost of the second-lowest silver plan available to them in their ZIP code.

Because they are treated as if their income is at 100 percent of the federal poverty line, they would also qualify for a cost sharing reduction, which would raise the actuarial value of their plan to 94 percent. They would need to purchase a silver plan to receive the cost-sharing reduction, which would significantly lower their deductible, copayments, and other out-of-pocket costs. (For more information on premium tax credits and cost sharing reductions, please see FAQ: Premium Tax Credits and FAQ: Cost-Sharing Reductions.)

Are there health coverage options for people who do not meet the immigration-related eligibility requirements for health insurance affordability programs? 

People who do not meet the immigration-related eligibility requirements for Medicaid but meet all other eligibility standards may be eligible for having limited treatment for life-threatening medical conditions paid for by Medicaid (including labor and delivery). People who do not have a documented immigration status or those with DACA are not eligible to purchase health insurance through the ACA marketplaces, but they may enroll private coverage outside the marketplace.

There are no immigration-related eligibility requirements for certain public health services including immunizations as well as services provided by Federally Qualified Health Centers, migrant and rural health centers, and hospital charity care. In addition, some states provide coverage of pregnancy services to people regardless of immigration status, and a few states and local governments provide health coverage to children without a documented immigration status and/or some adults that do not meet the immigration-related requirements for health insurance affordability programs.

People without a documented immigration status also can sign up for employer-sponsored insurance if their employer offers it.

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