“Healthcare Reform and Immigration Status in California May 13, 2014 Speakers Kellen Russoniello, Staff Attorney Health and Drug Policy, ACLU of San Diego & Imperial Counties Gabrielle Lessard, Health Policy Attorney, National Immigration Law Center Betzabel Estudillo, Health Policy Coordinator, California Immigrant Policy Center Basics of the Affordable Care Act Kellen Russoniello Staff Attorney Health and Drug Policy ACLU of San Diego and Imperial Counties
[email protected] May 13, 2014 ACLU of San Diego and Imperial Counties We fight for individual rights and fundamental freedoms for all through education, litigation, and policy advocacy Focus areas: Immigrants’ Rights Criminal Justice and Drug Policy Reform Voting Rights Overlap of ACA and Criminal Justice System Overview Medi-Cal Expansion Covered California Residency Individual Mandate and Exceptions Open Enrollment and Special Enrollment Periods Medi-Cal Expansion Provides health coverage to low-income residents Expanded Jan. 1, 2014 to cover most adults <65 years of age with incomes at or below 138% FPL $16,105 for an individual $32,913 for a family of four Eligibility for new population based on projected annual income (MAGI); assets not considered Full-scope vs. Restricted-scope Medicaid is a joint federal and state funded program. States administer the program and must conform to federal regulations. States must cover certain categories, such as aged, blind, disabled, and pregnant women and children. In California, Medicaid is called Medi-Cal. CA covers most optional categories and provides state-only funding for categories that the federal government won't pay for, such as lawfully present people who have been in the US under five years. Under the ACA and the Supreme Court ruling in 2012, Medicaid expansion became optional for states. California was one of the first states to expand. 250% FPL = $59,625 for a family of four MAGI applies to newly eligible, parents, children, and pregnant women. Coverage for certain categories will remain higher than 138% FPL. Children are eligible if household income is at or below 250% FPL = $59,625 for a family of four. Full-scope Medi-Cal is available where all eligibility requirements are met, including immigration status. This gives the full range of coverage, including hospitalizations, outpatient treatment, prescription drugs, mental health and substance use disorder treatment, and so on. Limited, restricted, or emergency scope Medi-Cal is available to those who meet income and residency requirements but are ineligible for full-scope coverage due to immigration status. Limited-scope Medi-Cal provides coverage for emergency, pregnancy-related services, and renal dialysis. 6 Covered California California's Health Benefit Exchange One-stop shop for insurance plans, including Medi-Cal (no wrong door) Four levels of plans based on actuarial value Advanced premium tax credits for 100%-400% FPL Lowers cost of monthly premium Credit equals premium minus percentage of income Percentage ranges from 2% to 9.5% Additional cost-sharing subsidies (silver plan only) Bronze, Silver, Gold, Platinum Cost-sharing reduction: Reduction of annual cost-sharing up to 400% FPL (2\/3 100%-200%, \u00bd 201%-300%, 1\/3 301%-400% Reduction of out-of-pocket expense at time of service up to 250% FPL. 100% FPL = $11,6700 for an individual and $23,850 for a family of four 400% FPL = $46,680 for an individual and $95,400 for a family of four 7 Covered California Cont. If eligible for Medi-Cal, not eligible for Covered CA If you are lawfully present and would be eligible for Medi-Cal but for immigration status, you are eligible for coverage through Covered CA. If your income is below 100% FPL, you will be eligible for the same amount of financial assistance as if your income was 100% FPL Example is a non-immigrant status, such as temporary worker or student 8 Residency Requirement for Medi-Cal and Covered California Live in California and: Have the intent to remain indefinitely, or Entered the state with a job commitment or to seek employment. Different than immigration status (e.g., can be a resident and undocumented) May be more difficult to prove for non-immigrant statuses (especially Medi-Cal) Cannot own or lease a principle residence outside CA. A person's declaration along with residency evidence submitted shall be accepted as proof of residency unless there is evidence to the contrary. This may present problems where a person's visa will expire after a certain term. 9 Individual Mandate Most people must have coverage or pay a penalty 2014 - $95 per adult\/$47.50 per child (up to $285) or 1% family income,* whichever is greater 2015 - $325 per adult\/$162.50 per child (up to $975) or 2% family income,* whichever is greater 2016 - $695 per adult\/$347.50 per child (up to $2,085) or 2.5% family income,* whichever is greater Pro-rated by number of months w\/o coverage * Maximum is national average premium for a bronze plan All citizens, permanent residents, and foreign nationals in the US long enough to qualify as resident aliens under tax law must have minimum essential coverage. Coverage on one day of the month is sufficient to avoid the penalty for that month. If you are exempt one day out of the month, the whole month is exempt. 10 Exceptions to Individual Mandate Not lawfully present Not a resident alien under federal tax law Religious objection Incarcerated Member of Indian tribe Income below tax filing threshold ($10,150 for an individual and $20,300 for a married couple filing jointly) Insurance more expensive than 8% of income Insurance gap of less than 3 months Hardship (e.g., homelessness, death of family member, financial hardship) Resident alien not so much an exemption as in the definition of who the mandate applies to. Nonetheless, if you are not considered a resident alien, then you do not have to pay the mandate if you do not have coverage. There are two tests to determine if you are a resident alien (you must pass only one): The first test is the \"green card test.\" If at any time during the calendar year you were a lawful permanent resident of the United States, and this status has not been rescinded or administratively or judicially determined to have been abandoned, you are considered to have met the green card test. 2. To meet the substantial presence test, you must have been physically present in the United States on at least: 1. 31 days during the current year, and 2. 183 days during the 3 year period that includes the current year and the 2 years immediately before. To satisfy the 183 days requirement, count: All of the days you were present in the current year, and One-third of the days you were present in the first year before the current year, and One-sixth of the days you were present in the second year before the current year. Migrant workers: Days you commute to work in the United States from a residence in Canada or Mexico if you regularly commute from Canada or Mexico do not count. You are considered to commute regularly if you commute to work in the United States on more than 75% of the workdays during your working period. Even if you meet the substantial presence test, you can be treated as a nonresident alien if you are present in the United States for fewer than 183 days during the current calendar year, you maintain a tax home in a foreign country during the year, and you have a closer connection to that country than to the United States. Students and teachers temporarily in the US on visa are exempt from treatment as resident aliens for a certain amount of time. 11 Open Enrollment NO OPEN ENROLLMENT PERIOD FOR MEDI-CAL! Can apply at any point throughout the year First open enrollment for Covered CA ended March 31, 2014 The next open enrollment period is November 1, 2014 February 15, 2015 Special Enrollment Periods 60 day enrollment period triggered by Qualifying Life Event: Become a citizen, national, or lawfully present person Loss of coverage Marriage\/domestic partnership Change of address resulting in new plans available (including release from incarceration) Change in income Have or adopt a child, or place a child in adoption\/foster care Applied before March 31 but denied Medi-Cal after March 31 Wrong enrollment due to Covered CA, insurance, or CEC Case-by-case decision Loss of coverage = due to losing job-based coverage, divorce, the end of an individual policy plan year in 2014, COBRA expiration, aging off a parent's plan, losing eligibility for Medicaid or CHIP, death of policy holder, and similar circumstances For changes in income, you must have been enrolled in a plan before the change in order to take advantage of an SEP. 13 Resources ACLU: ACA & Immigrants ACLU and CIPC Fact Sheet in English and Spanish ACLU Cheat Sheet English and Spanish IRS: Information on Individual Mandate Center on Budget and Policy Priorities: Special Enrollment Periods and Exemptions National Health Law Program Immigrants and health care In California Gabrielle Lessard National Immigration Law Center 15 National Immigration Law Center Our mission is to defend & advance the rights & opportunities of low-income immigrants and their family members. We envision a U.S. society in which all people - regardless of their race, gender, immigration or economic status - are treated equally, fairly, and humanely, have equal access to justice, education, government resources and economic opportunities, and are able to achieve their full potential as human beings. ROAD MAP Immigrants in California Eligibility Requirements Barriers Immigrants in California Highest Share in US: 10.3 million foreign born (27% of state pop.) 4.8 million naturalized citizens (47% of immigrants) ~2.3 million undocumented (7% of state pop.) ~23% of national undocumented population Mixed status families 18 Mixed-Status Families In Families with Citizens: Half of California children have at least one immigrant parent 90.4% of these kids are citizens 13% of California children have an undocumented parent Insurance and Health Care Access Immigrants are more likely than the US-born to be uninsured Immigrants use fewer health care services than U.S. citizens with the same insurance status (MPI, 2013) Undocumented immigrants use fewer health care services than citizens and lawful permanent residents with the same insurance status (UCLA, 2014) Fewer services when compared with USC with same insurance status Source, Migration Policy Institute, health Care for Immigrant Families: Current Policies and Issues (June 2013). 20 ROAD MAP Immigrants in California Eligibility Requirements Barriers Immigration Process Noncitizens enter the US lawfully: As immigrants on a path to lawful permanent resident (LPR) status As nonimmigrants admitted for a temporary stay As refugees admitted because they face persecution due to race, religion, nationality, political opinion, or membership in a particular social group Can adjust to LPR status Asylees are similar to refugees but apply for the status after entering the US Undocumented Immigrants Entered without inspection Stayed past the expiration of a temporary visa Deferred Action for Childhood Arrivals Deferred Action for Childhood Arrivals (DACA) Undocumented immigrants who arrived in U.S. before age 16 ( Dreamers ) Enrolled in or completed education leading to employment Continuously present since June 15, 2007 Coverage Options in CA Covered California state health insurance marketplace\/exchange Premium tax credits for families earning up to <400% FPL, and cost-sharing reductions for <250% FPL Medi-Cal expansion to 138% of federal poverty level (FPL) Other safety net programs E.g., federally-qualified health centers (FQHCs), community clinics, migrant health clinics, public hospitals, charity care Each has their own immigrant eligibility rules 25 Federal Benefits Eligibility In 1996, Congress divided lawfully present immigrants into two categories for federal benefits eligibility purposes: qualified and not qualified Qualified Immigrants can receive federal benefits, but many are barred from receiving federal benefits until they have been in the U.S. for five years California uses state funds to provide benefits during this 'five year bar' as part of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), 26 Qualified Immigrants Lawful Permanent Residents (LPR) Refugees Asylees Certain domestic violence survivors and their family members Certain trafficking survivors and their family members Iraqi or Afghani special immigrants (worked for US) Demonstrates that they were persecuted or fear persecution due to race, religion, nationality, political opinion, or membership in a particular social group 27 More Qualified Immigrants Other humanitarian entrants: Persons granted withholding of deportation or removal Certain conditional entrants (granted before 4\/1980) Certain Cuban\/Haitian entrants Humanitarian and Public Interest Parolees For a full list, see 'Lawfully Present' Individuals Eligible under the Affordable Care Act at http:\/\/nilc.org\/document.html?id=809 State Flexibility Under the unborn child option in CHIP, states can opt to provide prenatal services to pregnant women regardless of immigration status States can use their own funds to provide Medicaid\/CHIP to: Qualified immigrants during the five year bar People Permanently Residing Under Color of Law (PRUCOL) California has exercised all of these options Eligibility for Covered California lawfully present immigrants are eligible to purchase health coverage through state health care marketplaces no five-year bar exception: People who received deferred action through DACA are specifically excluded Lawfully Present Qualified Lawfully Present Immigrants All qualified immigrants People with permission to stay in the U.S. indefinitely temporary protected status (TPS) most with deferred action Applicants for LPR and certain other statuses People with valid nonimmigrant status not in violation of the terms of their visas Complete list: https:\/\/www.healthcare.gov\/immigration-status-and-the-marketplace\/ DACA Excluded from access to federally-facilitated, partnership, and state-run marketplaces\/exchanges No premium tax credits and cost-sharing reductions Exempt from the individual mandate No access to federally-matched Medicaid and CHIP California classifies DACA recipients as PRUCOL Can receive Medi-Cal if otherwise eligible For FAQ on DACA and Access to Health Care see http:\/\/nilc.org\/acadacafaq.html Undocumented Immigrants Undocumented residents can receive restricted-scope Medi-Cal Remain eligible for health programs that are available regardless of immigration status (e.g., public health programs) Hospitals must still provide emergency care regardless of insurance or immigration status Community health centers can continue to provide non-emergency health care regardless of immigration status Eligible to be covered by employer-sponsored group health insurance Insurance companies may offer insurance policies outside the state exchange(s) that are available to undocumented CA Programs Available Regardless of Status Emergency Medi-Cal Prenatal care (Medi-Cal) Access for Infants and Mothers (AIM) Long-term care Early Breast Cancer Detection Breast and Cervical Cancer Treatment California Children's Services (CCS) Children's Health Initiatives Health Programs in some counties (Healthy SF, Healthy Way LA Unmatched) Community clinics Child Health and Disability Prevention Program (CHDP) and CHDP Gateway Family PACT Minor consent services Mental health services Regional Center Services Women Infants and Children (WIC) School lunch and breakfast ROAD MAP Immigrants in California Eligibility Requirements Barriers Barriers Lack of information\/misinformation Concern that receiving benefits or having medical debt will interfere with ability to adjust immigration status ( public charge ) Fears about jeopardizing family members Belief that benefits will need to be repaid Confusion about eligibility Problems in application process Language barriers 36 Public Charge A public charge is a person considered primarily dependent on the government for subsistence, as demonstrated by: receipt of public cash assistance for income maintenance or institutionalization for long-term care at government expense A person who is found likely to become a public charge may be denied: Admission to the U.S., or Lawful permanent resident status Public charge is not a concern for: Medical benefits other than long-term care Other non-cash benefits (e.g., SNAP) People who are already LPRs Verification Citizenship or lawful presence is verified for all applicants Status is verified electronically through: Social Security Administration (SSA) for citizens. U.S. Citizenship and Immigration Services (USCIS) for noncitizens via the Systematic Alien Verification for Entitlements (SAVE) database. Income is verified electronically by the IRS If unable to verify status or income electronically, enrollees have an opportunity to provide other documents by upload, mail or fax. SSNs Only individuals who are applying for benefits are required to provide their immigration\/citizenship status. The Social Security Number (SSN) of a non-applicant may be requested to electronically verify household income. A non-applicant can be required to provide an SSN only if that person is: a primary tax filer, who has an SSN, and is applying for tax credits. Key Issues for Mixed-Status Families Undocumented people may apply for coverage on behalf of their dependent family members Applications should distinguish between applicants (e.g., U.S. citizen child) & non-applicants (e.g., undocumented parent) Non-applicants are not required to provide their immigration status Non-applicants without SSNs cannot be required to provide one Never provide an SSN unless officially issued by the Social Security Administration Individual Taxpayer Identification Numbers (ITINs) should not be used Information provided on an application may be used ONLY to determine eligibility for health insurance. 40 40 Immigration Enforcement Information about immigration status may be used only to determine an applicant's eligibility for health care coverage. ICE has released a notice stating that information provided in health insurance application process will not be used for civil immigration enforcement On October 25, 2013, U.S. Immigration and Customs Enforcement (ICE) issued a memo titled Clarification of Existing Practices Related to Certain Health Care Information, confirming that immigrant parents can enroll their U.S. citizen children and other eligible family members in health insurance programs under the ACA without triggering immigration enforcement activity. http:\/\/www.ice.gov\/doclib\/ero-outreach\/pdf\/ice-aca-memo.pdf \u00a1Now available in Spanish! http:\/\/www.ice.gov\/espanol\/factsheets\/aca-memoSP.htm Language Access Website is available in English and Spanish only https:\/\/www.coveredca.com\/espanol\/ Paper application is available in 11 languages Fact sheets are available in 12 languages, plus English Arabic, Armenian, Chinese, Farsi, Hmong, Khmer, Korean, Lao, Russian, Spanish, Tagalog, and Vietnamese https:\/\/www.coveredca.com\/fact-sheets\/ 42 Consumer Health Care Resources Stuck? Contact the Health Consumer Alliance: www.healthconsumer.org Direct access to Covered California 43 National Immigration Law Center: www.nilc.org National Council of La Raza: www.nclr.org National Health Law Program: www.healthlaw.org Center on Budget and Policy Priorities: www.cbpp.org California Immigrant Policy Center: www.caimmigrant.org Resources on Immigrants and Health Care 44 Undocumented & Uninsured SB 1005 (Sen. Lara) Health for All Betzabel Estudillo, MSW Health Policy Coordinator California Immigrant Policy Center 45 Founded in 1996, CIPC is a non-partisan, non-profit statewide organization that seeks to inform public debate and policy decisions on issues affecting the state's immigrants and their families in order to improve the quality of life for all Californians. CIPC engages in policy advocacy, and also provides technical assistance, training and education on immigrant issues. Why is Health4All important? Though the state provides health care services through programs with limited scope or duration, and some counties provide coverage regardless of immigration status, it is still not enough. Health Care system works better when everyone participates Emergency room treatment is expensive Cost Savings from other Health care spending Healthy Parents, Thriving Families Undocumented immigrants are a major economic engine for California, and contribute to the state's revenue Health is a Human Right Health For All-SB 1005 Introduced by Senator Ricardo Lara Press event on February 14th in LA Community members, advocates, and health providers were present supporting the bill Strong legislative support Co-authors: Senators Block, Calderon, De Leon, Evans, Mitchell, Padilla, Torres, Wolk Co-authors: Asembly Members Alejo, Ammiano, Bocanegra, Bonta, Campos, Dickinson, Fong, Garcia, Gonzalez, Roger Hernandez, Jones-Sawyer, Pan, V. Manuel Perez, Rendon, Skinner, Ting, and Yamada List of co-authorship continues to grow Health For All-SB 1005 What does the bill do? SB 1005 will expand access to health care coverage for all Californians, regardless of immigration status Full Scope Medi-Cal: authorize enrollment in the Medi-Cal program Mirror Exchange: offer insurance through a separate new health benefit exchange and provide premium subsidies and cost-sharing reductions to eligible individuals SB 1005 will ensure that everyone in our communities has access to quality, affordable healthcare. Undocu-CARE-Van Fighting for health justice! Inspired by the Undocubus CAREvan traveled over 600 miles to create awareness and advocate for SB 1005 Made 5 regional stops: San Ysidro, Santa Ana, Los Angeles, Pomona, Fresno Final stop in Sacramento on April 30th In each stop there was a townhall, press event, or community talking circle Where are we now? Senate Health Committee Hearing on April 30th at 1:30pm Status: 5\/1\/14- Do Pass and re-refer to Appropriations Committee (6 Ayes-1 Noes) Next Hearing: Appropriations Committee Date: Monday, May 19th Challenge: Fiscal impact, funding sources Greater challenge: Not providing access to care to ALL Californians How can I support? What can I\/my organization do to support? Get involved! Work with advocates Join community actions, town halls, Attend the hearing Share your story Share information in social media #Health4All #SB1005 For More Information www.caimmigrant.org www.undocumentedanduninsured.org www.undocuhealth.blogspot.com For Additional Information: Betzabel Estudillo, Health Policy Coordinator,
[email protected] Ronald Coleman, Government Affairs Manager,
[email protected] 55 Contact The Speakers Kellen Russoniello, Staff Attorney Health and Drug Policy, ACLU of San Diego & Imperial Counties
[email protected] Gabrielle Lessard, Health Policy Attorney, National Immigration Law Center
[email protected] Betzabel Estudillo, Health Policy Coordinator, California Immigrant Policy Center
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