State Medicaid and SCRIP Coverage of Noncitizens

Congressional research reportFeb 12, 2009

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Prepared for Members and Committees of Congress

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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.

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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

Figure 1. State and Locally Funded Medical Insurance for Otherwise Ineligible

Noncitizens................................................................................................................................... 9

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

Author Contact Information ...........................................................................................................11

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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 meanstested 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

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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

Legal permanent residents (LPRs) refer to foreign nationals who live lawfully and permanently in the United States.

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.

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.

It is premature to discuss how §214 of CHIPRA 2009 will be implemented.

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.

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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.

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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

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.

§401(c) of PRWORA, 8 U.S.C. 1611.

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.

§ 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

Fed. Reg. v. 67, pp. 61955–74, Oct. 2, 2002.

CRS Report RL34007, Immigration Fraud: Policies, Investigations, and Issues, by Ruth Ellen Wasem, pp. 10-12.

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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

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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

§1137 of the Social Security Act as amended by P.L. 99-603 and P.L. 104-193.

P.L. 104-193, § 432.

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.

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 ].

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.

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.

§ 213A of INA; 8 U.S.C. 1631. Fed. Reg., v, pp. 54346-56. Oct. 20, 1997.

§ 213A of INA; 8 U.S.C. 1631.

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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

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As noted above, states have the authority to provide Medicaid to LPRs following the initial fiveyear 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.

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 shortterm 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.

§ 421 of PRWORA. Also in 8 USC 1631.

§ 213A of INA; 8 U.S.C. 1631.

Fed. Reg. v. 62, pp. 45256-58, Aug. 26, 1997.

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.

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Table 1. State Policies on Noncitizen Eligibility for Medicaid in 2000 and 2006

2000

Total States Responding

LPRs present in the U.S.

before 8/22/96 were eligible

for Medicaid at state option?

LPRs, parolees, and victims

of abuse present on or after

8/22/96 were eligible for

Medicaid after the federal

bar expired?

Noncitizens admitted on

humanitarian grounds were

eligible for Medicaid at state

option after federal eligibility

period expired?

State offered state funded

insurance plans to cover

noncitizens not eligible for

Medicaid or SCHIP?

State offered locally funded

insurance plans to cover

noncitizens not eligible for

Medicaid of SCHIP?

State deemed immigrant

sponsor income or

resources?

State tracked immigrant

sponsors to enforce

reimbursement?

State had policy to collect

government reimbursement

under accountability rule?

2006

47 States, the District of Columbia,

and 3 Territories Responded

28 States and the District of

Columbia Responded

40 States, the District of Columbia, and

the U.S. Virgin Islands

28 States and the District of Columbia

33 States, 3 Territories, and the District of

Columbia

25 States and the District of Columbia

32 States, the District of Columbia, and

the U.S. Virgin Islands

23 States and the District of Columbia

15 States and the District of Columbia

8 States and the District of Columbia

15 States and the District of Columbia

10 States and the District of Columbia

5 States

16 States

0 States

1 State

0 States

1 State

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.

Source:

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.

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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

or SCHIP?

Medicaid or SCHIP?

State

2000

Alabama

Alaska

American Samoa

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

District of Columbia

Florida

Georgia

Guam

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

Yes

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2002

Yes

2004

Yes

2006

Yes

2000

Yes

2002

Yes

2004

Yes

Skip

Yes

2006

Yes

Skip

Yes

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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

or SCHIP?

Medicaid or SCHIP?

State

2000

New Jersey

New Mexico

New York

North Carolina

North Dakota

N. Mariana Islands

Ohio

Oklahoma

Oregon

Pennsylvania

Puerto Rico

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

U.S. Virgin Islands

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

Yes

2002

Yes

2004

Yes

2006

Yes

2000

Yes

2002

Yes

2004

Yes

2006

Yes

Skip

Yes

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

Source:

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 SCHIPfunded 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.

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.

Kaiser 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

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.

Source:

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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.

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

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.

§214(d) of H.R. 2 as passed by the House.

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.

According to the legislative language, the provision applies only to LPRs provided SCHIP and Medicaid under §214

of this Act.

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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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.

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Ruth Ellen Wasem

Specialist in Immigration Policy

rwasem@crs.loc.gov, 7-7342

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This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.