Immigrant Children with Special Health Care Needs and the Affordable Care Act

Immigrant children:

children who are foreign-born or children born in the United States who live with at least one parent who is foreign-born¹²

Mixed-status families:

families in which members have different immigration or documentation statuses⁵

Almost 25% of all children in the U.S. are immigrants.¹ Immigrant children are more likely than non-immigrant children to lack health insurance.^1,2,3 As an example, in California, 7.4% of immigrant children with special health care needs (CSHCN) are uninsured compared to only 3.3% of non-immigrant CSHCN.⁴ There is also significant state-to-state variation in health insurance coverage among documented immigrant children and pregnant women depending on whether or not they have been residing in the U.S. for at least 5 years. This is because some states have waived the 5-year waiting period for public health insurance coverage for lawfully residing children and/or pregnant women.^{8, 11} (See the states that provide Medicaid and CHIP Coverage of Lawfully Residing Children and Pregnant Women.)

Children are more likely to have health insurance when their parents are also insured.^{6, 7} However, when parents are not eligible for public benefits due to citizenship or documentation status, their children are more likely to be uninsured, even if they are eligible for coverage.^{6, 7, 13} This is common among immigrant children who live in mixed-status families.⁵ Citizen children in mixed-status families are more likely to be uninsured than children in families where all members are citizens.

Immigrant Children with Special Health Care Needs and the Affordable Care Act (ACA)

Immigrant CSHCN generally fall into one of three situations. Here is how the ACA may affect CSHCN in each of these cases:

Lawfully present CSHCN and parents with 5+ years in the U.S.

Parents of CSHCN with household with income <138% FPL will qualify for Medicaid in states that adopt the Adult Medicaid expansion.³
Lawfully present CSHCN are eligible to purchase coverage in the Marketplace and receive federal subsidies 8 and cannot be denied coverage because of a pre-existing special health care need (SHCN).¹⁰
The adult Medicaid expansion will fill a large coverage gap for immigrant parents. Prior to passage of the ACA, parents of dependent children were eligible for Medicaid in most states, but depending on the state, eligibility was based on household income as low as 10% FPL.⁸

Lawfully present CSHCN and parents with <5 years in the U.S.

CSHCN with <5 years in the U.S. can enroll in Medicaid if they live in states that waive the 5-year ban.⁸
CSHCN living in states that do not waive the 5-year ban for children, and parents of CSHCN with <5 years U.S. residency, cannot enroll in Medicaid.⁸
The Marketplace creates a second-tier safety net for individuals in this group who cannot get public coverage; this group is eligible to purchase coverage in the Marketplace (without a waiting period) and receive federal subsidies 8, and individuals cannot be denied coverage because of a pre-existing SHCN.¹⁰
Subsidized Marketplace coverage may remain unaffordable for individuals in this group who have incomes <100% FPL; even with subsidies, there will likely be out-of-pocket costs associated with coverage. Though small, these costs may be unaffordable for individuals who might otherwise (if not for their immigration status) qualify for Medicaid.³

CSHCN and parents with undocumented status

CSHCN with undocumented status are ineligible for Medicaid/CHIP.^{8, 13}
CSHCN with undocumented status are barred from purchasing coverage in the Marketplace, even if they pay full price.^{8, 13}
CSHCN with undocumented status can continue to receive care at community health centers (CHCs) regardless of immigration or documentation status (the ACA provides additional funding for CHCs).³

Provisions That May Address Inequities

Several provisions of the ACA have the potential to reduce health coverage inequities among CSHCN in immigrant families, who have historically higher rates of uninsurance than citizen children in citizen families; however, inequities likely will remain. There are persistent gaps in coverage for CSHCN with undocumented status or those who live in families where some members have undocumented status. Immigrants with undocumented status are projected to account for a quarter of all uninsured individuals after full ACA implementation.³ While the Medicaid expansion is mandatory for children, the optional expansion for adults will perpetuate coverage gaps for parents of CSHCN in immigrant families in some states. See Status of State Action on Medicaid Expansion Decision.

Barriers to Coverage

Additionally, immigrant families continue to face barriers to coverage related to:

Fear of jeopardizing a path to citizenship due to “public charge” determinations¹⁴
Fear of deportation for undocumented family members¹⁴
Language barriers

In mixed-status families, under the ACA, members who are eligible can apply for Medicaid or the Children’s Health Insurance Program (CHIP) [see Medicaid and CHIP Income Eligibility Limits for Children as a Percent of the Federal Poverty Level as of January 2014] or purchase insurance in the Marketplace, even if other family members have undocumented status or are otherwise ineligible. No disclosure of the documentation status of family members who are not applying for coverage is required, and if disclosed, will not be used for immigration enforcement.¹¹ Despite these protections, fears about enrolling in government benefits or being involved with public systems – due to a lack of trust in the government – may persist among immigrant families and result in eligible children remaining uninsured.¹⁴

ACA Provision	Impact on CSHCN in Immigrant Families	Gaps
Simplified Eligibility Rules for Parents and Caretaker Relatives, Pregnant Women, and Children This provision unifies children’s income eligibility for Medicaid for all children, birth to age 19, by expanding minimum income eligibility for 6 to 19 year olds from 100% FPL to 138% FPL. Optional Adult Medicaid Expansion Expands Medicaid eligibility to 138% FPL for childless, non-disabled, non-pregnant, lawfully residing adults, ages 19 to 64 in states that opt to expand.	Lawfully present 6 to 19 year old CSHCN with household incomes below 138% FPL with 5+ years U.S. residency, (or <5 years, in states that opt to waive the 5-year ban) are now eligible for Medicaid in states that previously limited Medicaid eligibility for this age group to <100% FPL. 3 Depending on a state’s Adult Income Eligibility Limit for Medicaid, lawfully present immigrant parents of dependent children with 5 + years in the U.S., and income up to 138% FPL, may now be eligible for Medicaid if the state adopts the adult Medicaid expansion.³	Newly arrived, lawfully present individuals, 19 and older, are still subject to the 5-year waiting period.⁸ (Newly arrived, lawfully present CSHCN and/or pregnant women may be covered within the 5-year waiting period—subject to income and residency requirements—if their state has chosen to waive the 5-year ban).⁸ Individuals with undocumented status remain ineligible for public health benefits.⁸ Deferred Action for Childhood Arrivals (DACA) grantees are not eligible. ⁸
Marketplaces The ACA created health insurance Marketplaces (also called “exchanges”) where individuals can purchase coverage if they do not have access to affordable, adequate employer-sponsored insurance (ESI). Federal subsidies are available for those with household income between 100 – 400% FPL.	Lawfully present parents of CSHCN can purchase insurance for themselves and their child(ren) in the Marketplace and receive federal assistance based on household income.9 If they are not eligible for Medicaid due to the 5-year waiting period, they can purchase Marketplace coverage and receive subsidies *even if income is less than 100% FPL*.¹⁶ No waiting period for purchasing coverage in the Marketplace or for receiving subsidies.⁹	CSHCN and parents whose immigrant status is undocumented (and DACA grantees) cannot purchase marketplace plans, even if they pay the full cost.⁹
Navigators All Marketplaces are required to provide outreach and enrollment assistance through Navigator programs.	Eligibility and enrollment assistance may streamline and simplify enrollment and clarify misconceptions for parents of CSHCN with limited English proficiency, resulting in higher enrollment.¹⁷	All states will have navigator programs, but in-person assistance – which may be most helpful in addressing language barriers – will vary depending on the state’s type of Marketplace.¹⁷
Pre-Existing Conditions Private insurance companies can no longer deny or limit coverage due to pre-existing conditions.	Lawfully present CSHCN and their parents with < 5 years in the U.S. can purchase coverage in the Marketplace without being denied a policy because of a pre-existing SHCN.¹⁰ This provision is extremely important for CSHCN, who require continuous coverage.¹⁰

References

1.Singh, G. K., & Lin, S. C. (2013). Marked ethnic, nativity, and socioeconomic disparities in disability and health insurance among US children and adults: The 2008-2010 American Community Survey. BioMed Research International, 2013, 1-17.
2. Avila, R. M., & Bramlett, M. D. (2013). Language and immigrant status effects on disparities in Hispanic children’s health status and Access to health care. Maternal and Child Health Journal, 17, 415-423.
3. U.S. Department of Health and Human Services. (2012). ASPE issue brief: The Affordable Care Act: Coverage implications and issues for immigrant families.   Washington, DC: Kenney, G. M., & Huntress, M.
4. Javier, J. R., Huffman, L. C., Mendoza, F. S., & Wise, P. H. (2010). Children with special health care needs: How immigrant status is related to health care access, health care utilization, and health status. Maternal Child Health Journal, 14(4), 567-579.
5. Urban Institute. (2011). Addressing coverage challenges for children under the Affordable Care Act. Washington, DC: McMorrow, S., Kenney, G. M., & Coyer, C.
6. Dubay, L., & Kenney, G. (2003). Expanding public health insurance to parents: Effects   on children’s health coverage under Medicaid. Health Services Research, 38(5), 1283-1302.
7. US Government Accountability Office. (2011). Medicaid and CHIP: Given the association between parent and child insurance status, new expansions may benefit families. Washington, DC: Government Accountability Office.
8. National Immigration Law Center. (March, 2013). Immigrants and the Affordable Care Act (ACA). Washington, DC: National Immigration Law Center.
9. National Immigration Law Center. (September, 2013). Health care for DACA grantees.   Washington, DC: Rejeske, J.
10. Catalyst Center. (2011). The Affordable Care Act: A side-by-side comparison of major   provisions and the implications for children and youth with special health care needs. Boston, MA: Catalyst Center.
11. Centers for Medicare and Medicaid Services. (2013). What do immigrant families need to know about the Marketplace? Retrieved from: https://www.healthcare.gov/what-do-immigrant-families-need-to-know/
12. American Academy of Pediatrics. (2013). Providing care for immigrant, migrant, and border children. Pediatrics, 131(6), e2028-e2034.
13. Georgetown University Center for Children and Families. (2012). Medicaid coverage for parents under the Affordable Care Act. Washington, DC: Heberlein, M., Huntress, M., Kenney, G., Alker, J., Lynch, V., & Mancini, T.
14. Kaiser Commission on Medicaid and the Uninsured. (2011). Connecting eligible immigrant families to health coverage and care: Key lessons from outreach and enrollment workers. Washington, DC: The Henry J. Kaiser Family Foundation.
15. National Health Law Program. (2013). Q&A on ICHIA: The legal immigrant children’s health improvement act. Washington, DC: Youdelman, M.
16. Kaiser Family Foundation. (2014). Health reform FAQs. Retrieved from
http://kff.org/health-reform/faq/health-reform-frequently-asked-question…
17. Kaiser Family Foundation. (2013). Helping hands: A look at state consumer assistance programs under the Affordable Care Act. Washington, DC: Kaiser Family Foundation.