Health Insurance Affordability Programs’ Eligibility Based on Immigration Status

Updated September 2022

Many individuals who are lawfully present in the United States are eligible for health coverage through Medicaid, the Children’s Health Insurance Program (CHIP), or subsidized plans in federal and state marketplaces. All U.S. citizens are eligible for these coverage programs, but there are immigration-related eligibility restrictions that block many people from qualifying for these health insurance affordability programs.

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What are the immigration status 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 created Two categories of immigration statuses used in determining eligibility: “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 they have not met a five-year waiting period after they obtain qualified status.  Individuals who are not eligible for Medicaid because of their immigration status may be eligible for Medicaid payment of emergency services, and some may be eligible for marketplace coverage. Additionally, states have the option to adopt broader eligibility rules for children and pregnant women who are immigrants.

Which categories of immigrants are “qualified” immigrants?

Categories of immigration statuses include:

• Lawful Permanent Resident status (LPR, or green card)
• Refugee status
• Asylum status
• Withholding of deportation/removal, or conditional entrants
• Cuban/Haitian entrants
• Individuals paroled into the United States, 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)
• Compact of Free Association (COFA) (Medicaid Only).

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 qualified immigration statuses do not have to meet the five-year waiting period requirement:

• Refugees
• Asylum
• Individuals granted withholding of deportation/removal
• Cuban/Haitian entrants
• Amerasian immigrants
• Trafficking survivors
• Iraqi or Afghan special immigrant status
• Veterans or individuals on active military duty and their spouse (un-remarried surviving spouse), or child
• Certain American Indians born abroad
• Individuals receiving Foster Care, and in most states, Supplemental Security Income recipients
• Some people arriving from Ukraine and granted parole into the U.S.

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 with a lawfully present immigration status. The term lawfully present 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. (See Table 1 for a full list of immigration statuses considered lawfully present for the purpose of enrollment in insurance affordability programs).

Under the CHIP option to provide prenatal services, states can use CHIP funding to provide prenatal care to people who are otherwise ineligible for Medicaid and/or CHIP regardless of their immigration status. In addition, some states use state or county funds to provide Medicaid and CHIP to other groups, such as people with lawfully present immigration statuses who do not have a qualified status and to children without a documented immigration status.^[2]

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

Only people with a lawfully present immigration status can enroll in a 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.

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, residence, minimal essential coverage, 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 does not have a qualified immigration status or has a qualified immigration status but has not completed the five-year waiting period). While Medicaid income eligibility differs in states that expanded Medicaid and those that did not, eligibility for premium tax credits for people with a lawfully present immigration status and incomes below the poverty line is not affected by a state’s decision on 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 2023.^[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 Key Facts: Premium Tax Credits and Key Facts: 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 prenatal 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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